GP Webinar: Q&A
GP Webinar: Discussion with Expert Panels
Moderator: Dr. Fazilah Shaik Allaudin
Panelists:
- Dr.Suresh Kumar Chidambaram (HSB),
- Dr. Suraya Amir Husin (MOH),
- Dr.Thirunavukarasu Rajoo (MMA),
- Dr.Ravindran Thayan (IMR),
- Dr.Priya Ragunath (MOH),
- Dr Nazrila Hairizan Nasir (MOH)
Q1: How about SARS medication to treat COVID-19?
A1: If patient fulfills the COVID-19 criteria, refer to the nearest designated hospital based on KKM COVID-19 Guidelines.
Q2: KKM should not limit testing to a few contacts only as this is now a PANDEMIC. Many symptomatic individuals returning from Indonesia and other countries have been turned away by KKM facilities, we may have missed many cases.
A2: The latest version of the COVID-19 guidelines is underway and will be released at the soonest. The updated list of countries is included in it.
Q3: Is the clinic setting considered close contact? How about in the wards? Also, what if our fellow colleague turns to be positive?
A3: In general, we have to see from a case to case basis depending on the contact i.e. how long, how close, if wearing PPE (masks) etc. Thus, it is important to practice standard precaution for all patients. Preferably screen patients before entering clinic with questions and if possible, mask them.
Clinic contact – usually considered a casual contact.
Ward – considered close contact if within the same cubicle, the other parts are casual contact if crossing paths.
Colleagues who are positive COVID-19 – depends on the contact that you have had with them.
One of the misconceptions is that doctors who are in contact with a COVID-19 patient are considered close contact. This is not true for doctors who wore PPE, you are not a close contact. Only if you were unprotected, then you are close contact.
Q4: Can we also have the updated list (from KKM) of qualified private centers doing COVID-19 screening?
A4: This will be updated soon and posted in KKM website under the topic COVID-19.
Q5: Can we use chlorhexidine / Clorox as we do not have sodium hypochlorite in the clinic? Clorox mixed with water? Chlorine dilution for disinfection?
A5: Clorox is sodium hypochlorite. Clorox is usually only used in small amounts. Hence, it needs to be diluted in water. Further list of domestic items that can be used to disinfect is included in the slide. Kindly refer to the list.
Q6: If a GP who is wearing a mask and maintains hand rub + IPC recommendations, if they develop URTI, should they be quarantined if they are exposed to a COVID-19 patient?
A6: Yes, he must be quarantined and even though low risk, they have to be screened in view of contact with COVID-19 positive patient.
Q7: Is it wise to give azithromycin to URTI patients?
A7: No, it is not because we don’t know if azithromycin monotherapy works and it is useless in URTI as this is a viral disease. We don’t recommend the use of azithromycin as it won’t work.
Q8: What is your view on use of rapid test kit as screening tool?
A8: Rapid test kits are antibody-based tests. What antibody tells you is that you have been exposed to the virus but it doesn’t tell you whether you are still carrying the virus. This will become positive in the 2nd or 3rd week of illness. 2 types of antibodies that can be tested by the rapid test. One is the IgM which comes after day 6 and the other is IgG which comes after 2 weeks. If a sample is taken on day 1, the person may have the virus but you may miss as it shows negative. But when you repeat on day 6, IgM may be seen but you are not sure if the person is sharing the virus. Therefore, these can’t be used for diagnosis. Diagnosis is needed within the first week of illness and to see if the preson is still sharing the virus so that we can contain it. The antibody will not tell you that. We tried this in Hospital Sungai Buloh and at day 7, 0% were positive and only 65% were positive on day 16. Therefore, it is not very useful in diagnosing COVID-19. IMR is currently testing the rapid test kit to obtain more data but at the moment, rapid test kit is not recommended for the diagnostic of COVID-19. But there is also a possibility of a rapid antigen test. This kind of test will be useful as a rapid test which can be done at the hospital setting with nasopharyngeal swab or a oropharyngeal swab where it can be dipped into the reagent for 20 minutes and we can get results. Some Korean company has developed it but it has not come to Malaysia yet. IMR people will test it out on site once it is available. If this can be done, this can be done to reduce the PCR turn-around time. If sensitivity is 50% the other 505 can go through PCR. This will bring down the workload of the labs.
Q9: I read a report stating anosmia is a peculiar symptom of a COVID-19 infection. Is this useful in anyway?
A9: We can’t ask them if they smell right in spite of all the other questions that we have to ask. Most of them are already in masks. I don’t think it is diagnostic of COVID-19. And I have not asked the question and I don’t think it is going to be useful in the diagnosis.
Q10: In a GP setting, we don’t know who we are exposed to, so, what would be the most appropriate triaging method? Temperature taking, travel history and/or both? In GP setting there is a severe deficiency in getting even a surgical mask.
A10: MMA has come up with a video which is a basic of what we should do with our limited resources. The video guides you step-by-step in dealing with the practical situation in a GP setting. The other issue is the scarcity of resources especially on PPE, hand sanitisers. MMA is working closely with MOH, we are getting as much as possible for the GPs. The frequent question asked by the GPs is “what do we do in the event of no masks or hand sanitisers, mainly ensure infection prevention and control to your patient and yourself, and if you have an issue, you can refer to CKAPS. The guideline is available. Treat everyone as COVID patient and take the necessary precautions with every patient. Always stick to wearing masks and taking proper history even before the patient enters the clinic. We are also appealing to the public to speak the truth about their whereabouts and contacts. Also if we as HCW develop any symptoms after seeing a COVID positive patient despite wearing PPE, we should get ourselves tested. So just remember the 4 most important things to stay safe as HCW based on the interim guidelines; make sure a symptomatic patient is given a mask, distancing is maintained, good and frequent hand hygiene and make sure the doctor is wearing a 3-ply mask. This is the minimum to be done for the cases that you attend to protect yourself. In a GP setting, do triaging and do symptom screening and not even asked to examine, then refer immediately if warranted. Maintain judicious use of PPE as it is very scarce.
Q11: What is your opinion on this virus being an airborne disease?
A11: We always knew it is airborne, but it is airborne only when you intubate or nebulise the patient i.e. during an aerosol generating procedure. But, otherwise it’s not airborne. Majority of the patients that we see in the wards are not airborne. The mechanism in most of the patients who are mildly symptomatic or have URTI is by droplet. Surgical mask or surgical mask with eye cover protects you. That is why the current guidelines says to stay 1 metre away from patients.
Q12: Any difference of technique used in IMR and private labs, e.g. BP lab/ gribbles for COVID-19 sensitivity wise?
A12: Multiple discussions have been made between IMR, MKAK and private labs regarding the testing. The private labs mostly use commercial kits. It is very tricky in terms of sensitivity and specificity as the single most important thing in the viral load testing is the way you take your swab. The test maybe negative if the swab is not taken correctly and we know the swab is not 100% accurate and it can’t be the swab alone. However, there has not been any formal comparative tests but the labs are using commercial kits and the protocols are widely available.
Q13: Should we refer all URTI cases with fever more than 38 degrees Celsius or when to refer?
A13: Eventually the travel history is not significant and anybody can come with COVID-19. Of course, we can’t test 30 million people every 2 weeks when they get URTI. Most people will look and do very well even with COVID-19. The people that won’t do well are usually the elderlies and people with co-morbid. We will know which group will do badly, these are the patients with persistent high fever, some may have shortness of breath or exertional dyspnoea or persistent cough. So, if any of these “danger signs” are seen they should seek treatment. And if the other patients come with URTI, with no such identified clusters or travel, the best is to home quarantine and explain to them what home self-surveillance is. This is based on UK NHS advice, once patients improve, they continue with their normal daily activity. If they don’t get better after a week, then we test them for COVID-19. We can’t afford to test everyone.
Q14: Why not advocate chloroquine for those under home quarantine?
A14: People have come up with many theories. But we do not know if it will really work in practice or not as there is not enough data to say if chloroquine or hydroxychloroquine can be a good prophylactic drug. Some data says it is useful in mild to moderate disease but we should not just use this drug without proper data as the virus may get resistant to it. Or, there might be a huge shortage of this drug and we can’t use it for people who really need it. We caution all of you not to embark on prophylaxis and make the already bad situation, worse. Let’s go by science and the science says there is not enough data. Only very limited science that says this. We need everyone’s help to make sure not to waste these precious resources based on rumours and stories.
Q15: Is it true that now cases are sporadic and no longer based on close contact?
A15: Yes, of course we have started seeing sporadic cases but majority of cases are linked to some cluster. This is shown in the daily report where the number of cluster and sporadic cases are stated.
Q16: Some private clinics offer test kits for detection of COVID-19. Is it advisable to do so under private clinic setting, with just masks and gloves? How about as a screening tool?
A16: As mentioned earlier, rapid kit test does not pick up patients in early disease. We are advising not to use rapid test kits as diagnosis as yet. It is only used as a public health tool but not for diagnosis.
Q17: 30-yo pregnant doctor at 5 months, exposed to COVID-19 positive patient. She was wearing a mask but the patient was not. Should she be allowed to continue to work?
A17: Go through the scenarios as stated in slides. But in general, it depends on the proximity of contact i.e. if the patient coughed on the doctor, etc. But, if it is a normal contact, then if she is wearing a mask, it is adequate. Hence, why we are encouraging everyone to wear a mask. But, there will always be nuances. General rule is, if it is a close contact than we will tell the doctor to go on quarantine and if casual contact we will just monitor and continue work.
Q18: What about a HCW with underlying asthma which is well controlled and still fit for work at GP clinic, PPE is used at the clinic, if the HCW is exposed to a COVID-19 positive patient?
A18: Well controlled asthma is not a risk factor for COVID-19.
Q19: Any evidence on favipiravir in treating COVID-19, has MOH acquired it and do we have it tested here in Malaysia?
A19: Very limited data from China stating that it is useful. It is currently not available in Malaysia but we are trying to acquire the drug from China.
Q20: Should we just close GP clinics in view of shortage of PPE? Would this burden MOH? If we come to a situation where we are forced to reuse face mask, is there any way to disinfect or sterilise the mask which has been used?
A20: In terms of practicality, the country is facing a crisis, we should play our role. Infection prevention and control is very important. If we are unwell, we can’t treat others. We need to understand the basic protocol of casual contact. Treat every URTI patient with temperature above 38 degrees Celsius as PUI COVID-19 protocol. Train your staff to ask relevant questions at the counter, keep a distance of 1 metre or more; give a simple script for them to ask at the counter. If temperature is above 38, tell your staff to isolate the patient in a separate room from others. Attend to the patient, don’t touch the patient, do a verbal and visual triaging and then decide. 80% of GP patients are repeat patients who come back to us and we know their history and most of them will tell us the truth. The 20% of first time patients, if you think there is a risk in your judgement during verbal and visual triaging, spend minimal time and send them out with adequate information of what needs to be done. Call them up after 1-2 days to check on them to reduce the risk in our practice. Let’s hope the situation with PPE will be resolved soon. MMA has issued numerous statements on PPE. In the meantime, we have all gone through training with minimal resources. Let’s look back on those experiences and put it to use now. This COVID-19 is a new and dynamic issue, we need to adjust according to situation but most importantly has to be evidence based. Let’s not panic.
From the infection control point of view, initially when we had the first 3 versions of the guidelines, we had on airborne precautions approach. When we realised it is more of a droplet precaution, the newer version we have added transmission based on droplet precautions. So, some of the precautions advised in the earlier versions are not applicable anymore.
As for the PPE if it can be reusable, according to the standard if it is advised as single use than it should only be single use. But due to the shortage of PPE, MOH is contacting all relevant agencies to meet our PPE supplies not only for MOH but for the whole of Malaysia.
Q21: The virus size is smaller than the 3-ply mask, is the 3-ply mask of any evidential protection?
A21: 3-ply mask is adequate for droplet precaution as mentioned earlier. But if you are performing Aerosol generating procedure than u need to use N95.
Q22: MMA with Pharma Malaysia only supplies 50 pieces of masks. Definitely not enough for us with many branches.
A22: We have scarcity of resources as we have 7000 clinics in the country. We have to make sure that every clinic staff and doctors are protected. That is why we are rationing at 3 boxes per clinic which is 50 pieces per in each box. We have to acknowledge that we are in a crisis and how to handle things in this period of time. Anyway, we also have 50-80% reduction in patient load in GP clinics. Hence, the usage may also be reduced.
Q23: Is it better to use MDI inhalers rather than nebulizers in this current situation?
A23: It is better to use inhalers than nebulizers as nebulizers can aerosolize and become airborne.
Q24: Is there any role for Tamiflu?
A24: Tamiflu doesn’t work for COVID-19 but if they have Influenza it will work.
Q25: Some Majlis Daerah are asking GP’s to close after 6 pm whereas we are supposed to close by 10pm as ordered by CKAPS. Which one should we follow?
A25: This is a legal question. What MMA can do at this moment is to get the directive from the MOH and escalate this matter to NADMA. At this point of time I cannot answer. We will communicate with NADMA and MOH and wait for the direction.
Q26: Based on a WHO paper, isolation and quarantine itself will not control the infection. We need to do aggressive screening tests to have better results in controlling the spread. What is our next step?
A26: Agreed. This is exactly the situation today. There is massive up scaling happening currently. The universities and army, private labs are all chipping in to increase the capacity for testing. Our DG wants us to test more so that we can identify and isolate patients.
Q27: Patients are not truthful and history is unreliable. Should we test for COVID-19 in every case of fever and URTI, assuming cost is not an issue?
A27: The issue again is the lab capacity. Our labs can’t cope to test all patients and GP’s should give proper advice to these patients, to self-isolate at home so as not to spread the disease to anyone else. In case the disease is getting worse, contact us so that we can test you. It comes back to the capacity of the lab. IMR and MKAK has trained about 18 centres in MOH facility and also trained private and university labs. But again the capacity is still a problem although now the capacity per day is about 3000. But we have more patients coming in so we have to ramp up double or triple. We are also looking at automation where we can quickly do the extraction and upload into an automation system. We can do all that when we have enough reagent. We are also looking at other options where there are companies where the system can test 96 samples at one go from Singapore. If this works it will be useful for Hospital Sungai Buloh.
Q28: If GPs close shop, what type of volunteer positions with MOH can we consider?
A28: The request for volunteers is not to place them immediately in any location but to standby as volunteers who can assist MOH if we come to a point where we cannot manage. These volunteers will not be actually used to handle or treat COVID-19 positive patients but more in other settings where their help will be needed. The recommendations on PPE will be according to where they are posted.
Q29: Is it necessary for us to wear gloves during consultation?
A29: No, mask alone is sufficient. But, adhere to frequent hand-hygiene practice. Universal gloving may contaminate other surfaces. Gloves are only for collecting samples and cleaning and not for routine physical examination.
Q30: Is MOH considering following Korean way of setting up drive-thru mass testing facilities? According to JAMA, can we consider self-swab COVID station? What is your opinion?
A30: Drive-thru testing have been done. Self-testing swab (throat swab) has no data as yet and most tests are performed by someone on the patient. The needs a nasopharyngeal swab and not a throat swab. Indicated sample collection is nasopharyngeal swab and throat swab is not recommended.
Q31: How long should we adhere to house quarantine; asymptomatic casual contact and symptomatic casual contact? Judging by the fact that the incubation period can range from 5-14 days and disease progression is up-to 26 days.
A31: It does not matter if you are symptomatic/asymptomatic as once you have had contact, your days start from the point of no contact. 14 days from that day. If you are to get the disease, you will get the disease (symptoms) within that 14 days as that is the meaning of incubation period. If you develop symptoms than you get tested but if you are getting better than that is it. For those under home surveillance and tested, day 1 PCR maybe negative but seroconversion occurs by day 13 so you will already have the antibodies. So, on day 13 you can do the rapid test which is an antibody test is adequate. This also helps to reduce the burden of the lab to perform PCR test.
Q32: Are private hospitals allowed to treat COVID-19 patients, if these patients have insurance coverage?
A32: Currently, no private hospitals are allowed to treat COVID-19 patients. They have to refer to the government hospitals.
Q33: Would you consider money as a factor that transmits the virus and encourage the use of e-wallets?
A33: We have to selectively swab the money to see if virus is present. We really do not know. we are not going to comment on that without any evidence.
Q34: What is the risk of examining the throat of any patient with febrile URTI?
A34: You have to wear a mask and preferably eye protection as well before you check anybody’s throat. If you are very near to the patient and anticipate that the droplets would be aerosolized than you actually have to wear N95 mask and a face shield. If not aerosolized than a simple surgical mask is adequate.
This article was prepared by:
Dr.Zawaniah Brukan Ali, Dr.Noor Amelia Abd Rasid and Dr.Sara Sofia Yahya
Medical Development Division, Ministry of Health Malaysia
