Stop the cover up: Disease doesn’t discriminate

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Efforts to raise public awareness of leptospirosis prevention measures appear to be more low key in contrast to past and ongoing health campaigns for dengue, SARS, and AH1N1, observes Angeline Loh.

A crowded immigration detention camp in Malaysia

The Health Minister’s statement in August that only nine lives “so far” have been claimed by leptospirosis (The Sunday Star, 22 August 2010) is misleading and disturbing.

Leptospirosis fatalities were publicly known to have occurred amongst Immigration Detention Camp (IDC) detainees in Malaysia since 2009. However, in 2000, the Public Health Agency of Canada had made a public announcement that several US athletes participating in the EcoChallenge Sabah 2000 became ill with fever and muscle aches upon returning home. Lab tests carried out indicated they had contracted leptospirosis from the water sports event held in Sabah, Malaysia that year (Public Health Agency of Canada, Infectious Diseases News Brief, 22 September 2000).

May 2009 saw a slew of NGO and media reports of migrant detainee deaths when the deaths of two Burmese detainees in Juru IDC, Penang, were followed by news of six more deaths reported in September at the KLIA detention centre (NGO Joint Statement, Workers Hub for Change, 25 September 2009) and two more deaths in Lenggeng IDC in October the same year (Charles Hector, 31 October 2009).

It was also reported by the media in 2008 that there were 1,300 deaths amongst foreign detainees in IDCs due to “neglect”(Charles Hector, 24 June 2009). Concerned NGOs came out strongly against delays in allowing access to medical treatment and at the apparent government apathy to ensure hygienic conditions and clean environment within the IDCs and other places of detention. This was only the tip of the iceberg of the potential number of leptospirosis deaths in the country.

Appeals were also made to Suhakam. The national human rights institution responded positively, aptly describing this “neglect” and delay in allowing detainees access to medical treatment as a violation of human rights and “a serious violation of …person’s right to life” (Charles Hector – Alternative Malaysia, 24 June 2009). A May 2009 joint statement against the denial of timely medical treatment and squalid, unhygienic conditions in IDCs following the deaths of the two Burmese Juru IDC detainees was endorsed by as many as 126 internationally based groups and organisations (Charles Hector ibid).

Despite these alarm bells, the Home Affairs Ministry and the Health Ministry continued to take a lackadaisical attitude, treating the issue with minimal concern. The Home Affairs Ministry promised to ensure more hygienic conditions within the IDCs (Pemberi-tahuan Pertanyaan Bagi Jawab Lisan Dewan Rakyat, Rujukan 2098).

Although some measures may have been taken, there does not seem to be any adequate or permanent solution to the problem of scarcity of medical treatment in the IDCs. It was disclosed to the author recently that government medical teams were not servicing Juru IDC, due to a shortage of hospital staff. This gap had to be filled by NGO medical teams, which provide health care and medical treatment to migrant detainees (Source: NGO).

Public and media awareness of the seriousness of the situation within the IDCs seemed to die down with promises and short-lived action taken by the government to briefly appease human rights and migrant rights advocates – until the disease resurfaced recently outside the IDCs in riverside recreational locations in Pahang (Malaysiakini, 10 July 2010) and Kedah (The Star Online, 5 August 2010) in Peninsula Malaysia.

Govt inaction in peninsular Malaysia

When the leptospirosis deaths of the six Lubuk Yu, Maran rescuers were publicised by the media, the government’s immediate reaction was to close the forest river recreational area (Bernama, 10 July 2010, www. flutrackers.com). Water and soil samples were lab tested and confirmed to host leptospirosis and melliodosis bacteria. Leptospirosis is spread via rat urine and can infect other animals and humans.

A Hong Kong 2001-2007 Report describes the disease as follows,

“Leptospirosis is a worldwide zoonotic disease caused by the genus Leptospira. The bacteria may be free-living or associated with animal hosts and survive well in fresh water, soil, and mud and have been found in rodents, cattle, pigs, dogs, and wild animals. Human infection might occur through contact with water or soil contaminated by urine from infected animals through skin abrasions, open wounds or mucous membranes; occasional infections occur through ingestion/ inhalation of food/droplet aerosols of fluids contaminated by urine. The disease is normally not transmitted from person to person. The incubation period is usually between 5 and 14 days and can be as long as 30 days.”
(Source: Communicable Diseases Watch August 19 – September 1, 2007, Vol.4 No.18)

The symptoms are described as follows,

“The most common symptoms in persons who have leptospirosis are fever, chills, red eyes, stomach ache, vomiting, and diarrhoea. The disease is often not diagnosed properly. If the disease is not treated properly, patients can suffer kidney damage, meningitis, liver failure, and breathing problems. In rare cases death can occur.”
Source: Press Release, Centres for Disease Control and Prevention, September 13, 2000

The same government procedure as in Maran, Pahang followed the discovery of the disease in Lata Bayu, Kedah with no further steps taken except to warn the public to avoid engaging in outdoor water sporting and recreational activities until the “all clear” was given by the Health Ministry (The Star Online, 5 August 2010) in media statements relating to these incidences in West Malaysia.

On 13 July 2010, the Health Minister was reported to have urged the Chinese press “not to sensationalise” the six Lubuk Yu deaths in Pahang. He reassured the public that the Ministry knew the cause of the deaths and had the antibiotic to treat it (Malay Mail Online, 13 July 2010).

In relation to this announcement, it must be pointed out that in the IDC leptospirosis deaths, Immigration and Health authorities were reluctant to disclose the cause of death of migrant detainees.

Human rights activist Charles Hector said,”Well, we have been informed that two more Burmese migrants in detention have died of disease. But what disease? Was it again Leptospirosis? One of the deceased … died on 22 October 2009. The hospital did not say what disease he died from. He was buried on 29 October 2009.” He continues, “We have a right to be informed of disease outbreaks and deaths in places of detention in Malaysia.” (Charles Hector, 31 October 2009)

In a press release on 16 July this year, Director General of Health Dr. Ismail Merican announced that out of the six rescuers in Lubuk Yu, two had recovered from leptospirosis/melliodosis and had been discharged from the hospital and one in Selayang Hospital’s ICU was in a stable condition.

Screening conducted in villages near the site of the disease outbreak “detected six residents with fever” who were said to be in stable condition ( MOH Press Release, 16 July 2010). The risk of infection, he said, was low as these villages were not involved in the rescue effort at Lubuk Yu, Recreation Centre, Pahang. People with skin lesions were advised to stay away from contaminated water and soil, as bacteria was easily spread via these two elements. The public was reassured that leptospirosis/melliodosis was not contagious as it was not communicated human-to-human.

What is disturbing about this government statement is that the public are not told how the six villagers contracted ‘fever’ although they were not involved in the river rescue effort and apparently had not been in direct contact with the contaminated site. Moreover, D-G Ismail Merican’s reassurance and apparent confidence that the risk of infection is low is not convincing as the information given is ambiguous and raises several unanswered questions.

However, the Health Ministry announced on 7 August 2010 that leptospirosis is now classified as a ‘notifiable disease’ (Borneo Post Online, 8 August 2010). Why did the need to monitor the situation arise, if there was no outbreak or danger of the possible increase in the incidents of infection?

The Ministry says it has repeatedly reminded the public to maintain cleanliness of the environment in living areas, not to allow accumulation of garbage that can attract rodents and other vermin, and to avoid outdoor activities and camping holidays until further notice. The adequacy of this warning was, however, doubtful as no concrete measures seemed to be taken apart from making these media statements. The Health Minister said the Ministry would “distribute leaflets and posters to raise awareness of the diseases” (Yahoo! News, 23 August 2010).

The Ministry appears to prefer to play down the dangers of leptospirosis and ignores the possibility of rodent infestation, which seems more noticeable with rats seen scuttling around in the open in broad daylight. More rats than health inspectors or council pest exterminators are sighted around local food outlets and residential areas.

Borneo’s febrile disease experience

As mentioned at the beginning, the occurrence of leptospirosis in Sabah, East Malaysia was already publicised by foreign sources at least 10 years ago – i.e. the public announcement made by the Canadian Public Health Agency. This was not the only public announcement to come out in 2000. A 21 September 2000 Euro-surveillance report disclosed that 312 athletes from 26 countries participated in the EcoChallenge 2000 in Sabah, Malaysia, and several cases were diagnosed with leptospirosis.

Moverover, “investigations in the United Kingdom (UK) and United States (US) suggest that a half of participants may have suffered febrile illness since the race” (Baranton G, Evans M. Leptospirosis outbreak in Eco Challenge 2000 participants. Euro Surveill. 2000;4(38):pii=1523. Available online).

In the intervening period, virtually nothing appears to have been mentioned by the government or the media of the existence of leptospirosis and melliodosis in rivers and soil in East Malaysia until after the the Lubuk Yu (Pahang) and Lata Bayu (Kedah) incidents in Peninsular Malaysia.

Malaysiakini’s Bahasa Malaysia version reported on 29 July 2010 suspicions that the occurrence of melliodosis (a soil and water bacteria) amongst workers at the Bakun Dam project was being suppressed by the Sarawak Health Department. Officers from the state’s health authority claimed they had received a July circular prohibiting any disclosure of information regarding the melliodosis cases found at the Bakun Dam project site. The officer interviewed was also prohibited from revealing the reason for non-disclosure of the information (Malaysiakini, 29 July 2010 – ‘Kemungkinan melioidosis dirahsiakan di Sarawak’).

Health Ministry Director -General Ismail Merican and an official from the Department for Communicable Disease Control (DCDC) both denied knowledge of the alleged prohibition to disclose information on the incidences of mellioidosis amongst workers at the Bakun Dam project. The DCDC official, who remains anonymous in the report, is said to have invited anyone who wanted such information to make a request in writing to the DCDC (Malaysiakini ibid).

Disclosures by a management staff member of a sub-contracted company for the Bakun Dam Project (BDP) are even more alarming. Apparently, a part of the migrant workforce on the BDP had caught the infection since the start of the project last year. Nine deaths had already occurred and 50 more had recovered at the time after receiving medical treatment. Migrant workers contracting the disease had also been repatriated after recovery as illness was said to recur even after treatment.

The company management was alleged to have repatriated 10 migrant workers last year and some (it was claimed) had been repatriated without medical treatment. Those who had died did not receive medical treatment early as they had not reported being ill to the management for fear of termination and repatriation. This group had been involved in land drilling work and were thus exposed to infection. Two workers and a Belaga villager were at the time in the intensive care unit at Bintulu Hospital. It was feared that the disease would also spread to workers working on the Murum Dam Project (Malaysiakini, 29 August 2010)

Dr Hu Chang Hock, Malaysian Medical Association (MMA) sub-branch advisor, gave further clarification to the public on the causes and symptoms of mellioidosis/leptospirosis. He informed the public of prevention measures and to seek timely medical treatment as soon as symptoms emerged. Despite saying that chances of contracting these diseases in the home environment were small, he still stressed that rats were pests and capable of spreading diseases (Borneo Post, 16 August 2010).

However, on 12 August, Sibu Municipal Council Deputy Chairman Daniel Ngieng advised parents and children to avoid the Jalan Permai Lake Gardens. The Council was also “mulling over launching a Rat Control Campaign to rid the town of the disease- bearing pests” (Borneo Post Ibid).

Govt: No leptospirosis

Ironically, on 31 July 2010, Sarawak Deputy Chief Minister George Chan publicly declared, “As far as I know, there is no outbreak and I have checked the medical report from the Health Department to ensure there is no panic in the Bakun area because even though leptospirosis is not on the list of notifiable diseases, the administrative notification was implemented in Sarawak in 2003” ( Bernama, 30 July 2010, Flutrackers, ‘Summary of Current Leptospirosis Outbreaks in Malaysia 2010’).

He claimed the 29 July Malaysiakini report to be untrue yet admitted that, there were “three positive cases, including two deaths, in Lubuk Antu and Bintulu out of the 36 admitted to hospital for suspected leptospirosis so far this year”. Five cases proved negative and test results for the remainder were awaited. Bintulu had 14 suspected cases, Sibu eight, Miri four, Kuching three, Kapit three, Saratok and Sarikei had two each, Sri Aman and Lubok Antu one each. Altogether 157 people were admitted to government hospitals throughout Sarawak for leptospirosis in 2009 with no reported fatalities (Flutrackers ibid).

Therefore, at the time of the DPCM’s statement, there were close to 40 known febrile illness cases in Sarawak and 157 confirmed admissions for leptospirosis within the year. Was this not of concern to the State and Federal Health authorities? Did the absence of known fatalities mean that there was no outbreak of the disease in the Sarawak, when suspected infection seems to be rising?

Commenting on the case of a seriously ill Chinese Bakun project worker, he said, “It is just a suspected case and the condition of the Chinese man is quite severe,” adding that, “he could not confirm if the man is a foreign national. “It is not an outbreak. We are telling about the disease because we want to be more careful” (Bernama, 30 July 2010).  Why was there a need for caution when there was no outbreak?

According to the Deputy Chief Minister, there were 74 admissions for leptospirosis in government hospitals that year. Bintulu, Sibu, Kuching and Kapit were said to have the highest number of known incidences. But no reported deaths (Flutrackers ibid).

Not only are the Sarawak State government and health authorities dismissive of the seriousness of the situation, the Health Ministry shared a similar attitude by saying the situation was under control and that the “public should not be unduly alarmed”(Malaysian Mirror, 7 August 2010).

Pahang Environment and Health Local Government Committee chairperson Hoh Kai Mun, publicly declared the leptospirosis “epidemic” over on 2 August 2010 (Malaysiakini, 3August 2010), when no new suspected cases were reported 28 days after the Lubuk Yu cases came to light. Yet, 22 suspected cases of leptospirosis/mellioidosis were reported on 3 August (Star online, 5 August 2010). Nonetheless, 89 people had been involved in the Lubuk Yu rescue effort and all were diagnosed with leptospirosis/ mellioidosis (Star online, 6 August 2010)

An online media portal recently reported a rise in leptospirosis cases in Malaysia, claiming the number had increased fivefold to over 1,400 from 263 in 2004 and deaths from 20 to 62 within the same period (Globe and Mail, Update, 23 August 2010).

Time to wake up

The Health Ministry as well as local government health departments have made numerous public statements about the occurrence of leptospirosis/mellioidosis disease in various locations in the country. Yet, few of these statements touch on the existence of rats in crowded urban areas where food outlets and garbage dumps are more ubiquitous and conducive for rat infestation.

However, Health Minister Liow Tiong Lai cautioned the general public to patronise clean food outlets to make sure the food they consumed was not contaminated with leptospirosis bacteria. (Utusan Malaysia online, Berita Utama, 7 August 2010). With the destruction of more forested land for urban and residential development at an accelerated pace coupled with floods due to climate change, the possibility of the wider spread of febrile disease should not be discounted.

Medical and scientific reports have documented the occurrence of leptospirosis since the First World War and the disease has been recognised as an occupational hazard for army personnel, particularly those involved in jungle operations (Malaysian J Parhol 1979, Leptospirosis In The Malaysian Army, V. Supra-maniam MBBS, MSPH*Staff Officer (Health) Medical Directorate, Ministry of Defence, Kuala Lumpur). National Service camps in Perak also stopped water activities after the Pahang and Kedah reports (Malaysian Insider, 17 August 2010)

Medical research reveals that the infection can be acquired through indirect contact with “…soil, mud, fresh waters, vegetation, foodstuffs and working place infested with rodents” (Asean Review of Biodiversity and Conservation (ARBEC) Jan-Mar 2003).

Yet, efforts made to raise public awareness of leptospirosis prevention measures in contrast to past and ongoing health campaigns for prevention of dengue fever, Sars, and AH1N1 appear to be more low-key. There is no wide media coverage emphasising the need for stricter domestic and commercial cleanliness and hygiene regimes. Nevertheless, the government acknowledges that this disease is “deadly” (theSun, 15 August 2010), difficult to diagnose, and there is no vaccine for immunity to the infection, the only means of avoiding fatality being early treatment with prescribed antibiotics (NST online, 14 July 2010).

Further, although leptospirosis is not a listed notifiable disease under the Centres for Disease Control and Prevention Act Malaysia (Borneo Post online, 31 July 2010), it is noted that “… all cases amongst soldiers are reported to the appropriate authorities including the Medical Directorate at the Ministry of Defence by medical officers on the ground” (‘Leptospirosis in the Malaysian Army’, V. Supramaniam ibid).

Whiles it is important to protect the health of those in the armed forces who defend our country, the necessity to protect public health should not be diminished. It is also unwise to establish a hierarchy of rights to health where migrants and foreign detainees are afforded less rights than any citizen to accessible and timely medical treatment. Disease does not discriminate between citizen or foreigner; it simply strikes the most vulnerable who are exposed to it.

Note: At the time of writing another leptospirosis death in Kedah was reported bringing official numbers to 10 (Yahoo! News, 23 August 2010).

Angeline Loh is an Aliran exco member

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