By Datuk Dr Ghazali Ahmad, (MBBCh Hons, MMed, FRCPI, AMT, KMN, PJN Consultant Nephrologist , IJN)
THREE Fridays ago, a group of doctors from the Ministry of Health headquarters, those representing hemodialysis services in the Private Sectors, NGOs and the Malaysian Society of Nephrology met in Putrajaya.
They discussed a proposal to have an SOP for the management of Person Under Investigation (PUI) and positive cases of COVID-19 involving either patients, their accompanying persons and healthcare professionals in the dialysis unit.
The need for a clear practice guidance and suggested process and procedure is not just in anticipation of COVID-19 positive cases among patients on dialysis treatment, care givers and those in close contact with them including healthcare professionals but also on the following facts :
1. There are more than 46,000 patients with end stage kidney disease, out of which >42,000 are on regular dialysis treatment in the country with 90% of them on outpatient, in-centre hemodialysis as opposed to 10% of home-based Peritoneal Dialysis treatment.
2. They receive treatment in >900 dialysis units all over the country, out of which 894 are hemodialysis (HD) units.
3. Almost all patients on HD are on thrice weekly treatments lasting 4 hours per session which cannot be skipped to avoid serious adverse health consequences including possible fatal outcome, regardless of whether movement control order (MCO) or curfew is in place.
4. Only specialized nurses trained in performing hemodialysis and familiar with the complications on dialysis are permitted by standards and regulation to perform HD procedures. These staffs have to commute daily to the HD units including on Saturdays or Public Holidays as dialysis must continue to avoid deaths to patients.
In addition, almost all patients on dialysis will have additional health factors making them at increased risk of acquiring COVID-19 infection. Apart from being generally immunocompromised, 67% percent of them have Diabetes Mellitus, more than 50% hypertensives and 47% are older than 55 years of age.
Having an agreed standard on what to do and a uniform way of handling either a PUI, asymptomatic contact with PUI or an actual case of COVID-19 in the dialysis unit will hopefully streamline, facilitate and expedite care in an efficient manner.
Like in any other situation when a group of people meet to agree on a document, similar challenges were encountered on that day when we met as the problem began to unfold in front of us with so many possibilities affecting the general public and factors to take into account making any such document to be applicable in all situations all the time becoming impossible.
A general policy applicable to non-dialysis subjects and clinical staffs not working in the dialysis unit may not necessarily be suitable in the setting of management of end stage kidney disease patients on dialysis, especially for those in-centre hemodialysis. This unsuitability will be clearer as we discuss real case scenarios below:
In the beginning, the official policy on the screening tests for COVID-19 only prioritize those who had returned from recent travels to high endemic countries especially China, Korea and Iran.
Others included those with contacts of positive cases and those with positive symptoms of fever, cough and shortness of breath. As the awareness on the importance of physical and social distancing became clearer, those in contact of index cases especially within a distance of one meter for a 15-minute exposure became added as another factor to consider.
What the participants of the meeting did not know for sure then was whether the guidance on screening and testing formulated was solely based on the clinical evidence from the affected countries (this could not be the sole reason as Korea was already performing wide scale case detection by testing as many subjects as possible to diagnose compared with China earlier), or due to the supply issue.
The demand was already there from the beginning , and if the epidemiologists have their sway and the budget for test kits were requested with vigor in a convincing way, it would be unfair to the nation and ill advised to the patients, families, employers and the front liner clinical staffs, if the fund provider were short sighted and stingy when they were appropriately presented with the request by the Ministry of Health. Which is which is unclear.
But as we were discussing the way forward, one of the private kidney specialists in attendance received a call from his HD unit nurse. He had apparently been in direct contact with two Covid-19 positive patients from the Jemaah Tabligh cluster. The two had temporarily dialysed in his HD unit while they were outstation in the Klang Valley for the religious congregation.
A brief panic-stricken atmosphere spontaneously descended in the meeting room, short of a mayhem.
Many spontaneous, no longer hypothetical, questions sprang up. How far did one sit bedside the specialist doctor who had suddenly become a PUI.
Who did he shake hands with, did he?
The doctor must had wildly thought of a few questions on the effects of direct contacts on his own health but more importantly what to do with the two patients who had subsequently returned to their respective units elsewhere, to the other regular patients in his unit who may have been exposed to the infection and more importantly his valid worries on the implication of the exposure to his valued and precious dialysis nurses.
Similar thoughts must have gone through the heads of his nurses while the poor specialist have to figure out what to do. Suddenly the draft SOP document received its first field test in the ‘situation room’.
With more countries reporting new cases coming to their shore including far away countries beyond the Asian region, hitting some of them very hard as we now learn Iran and harder even in Italy, it looks clear that this ‘blessed country’ and ‘the land of plenty’ is not just going to deal with tourists coming to Malaysia from Guangzhou and Shanghai with travel bookings made well before the Visit Malaysia Year 2020 was launched in glitters in Padang Merdeka on the eve of the new year by the then PM Tun Dr Mahathir, but also returning Malaysians from overseas tours , far and near.
While the thermal scanners erected at the main airport gateways were looking at the raised temperature of the bodies scanned, little was it realized then that many of those who carried the virus, now newly minted as COVID-19, may not have any symptom in their incubation period variously estimated at between 2-3 weeks from the time of the initial exposure.
So began the free mix and match game of spreading the infectious virus by both the `foreign agents’ as well as by the citizens themselves, while the capacity to make an accurate diagnosis e was hampered by mixture of reasons varying from the lack of awareness by the public and healthcare staffs, unavailability to confirm a diagnosis with a validated and standardized test method and a lack of clear guideline on who, what, where and how aspects of screening, diagnosis ,and management.
When things were clearer with terms like Close Contacts, Person Under Investigation (PUI) etc coming into picture with definitions spelt out by the Geneva based World Health Organization, local public experts who had dealt with problems like SARS and MERS-CoV in the past started giving media responses to calm down the listeners that with our broad and deep experience in managing such past infections, the country is ready to face any likelihood or fall out from the new viral outbreak.
Guidelines on testing and management of the public and healthcare workers, sign and symptoms to assess and record, a systematic method of tracing and contacting those exposed to the case diagnosed began to appear for use by the healthcare workers and a guide to the public.
But when a 68 year pensioner with end stage kidney disease on regular hemodialysis presented to a major public hospital in the capital with fever and a bit of sore throat in the morning of 18th March – 8 weeks after the diagnosis of the first case in the country on 25th January 2020, and an accumulative 900 cases were confirmed with COVID-19 across the country — the patient was labelled as viral fever, told to go back for his regular hemodialysis in his HD unit and told not likely to have COVID-19 due to negative contact with a PUI or COVID-19 patient.
Certain that COVID need to be excluded, the doctor in charge of the haemodialysis unit requested the patient to meet the medical officer in the Emergency Department again.
After waiting for many hours, he was reexamined and admitted to the kidney specialty ward of the general hospital.
However, a diagnosis of infection related to the hemodialysis catheter was entertained and tests for COVID-19 was not considered as this was not clearly stated in the prevailing ministry circular at the time.
After 5 days of admission, and after having many doctors and nurses in direct contact with the patient, a request to exclude COVID-19 was made to the lab. From that point, it took another 3 days for the result to come back positive nearly at midnight, exactly 8 days from the day of admission.
This time, it was a real mayhem, for the real.
The doctors and nurses and other nearby patients in contact with the newly diagnosed patient have to be identified.
The doctor in charge of the hemodialysis unit, where the patient had his regular dialysis, have to be contacted in the middle of the night, before the next group of patients appear at the doorstep next morning for hemodialysis treatment.
Other steps in damage control have to be worked out, not just to get the affected patient in hospital treated but also decide what next needs to be done to contain the infection and prevent another explosive cluster from adding the number to the national statistics in the subsequent days.
This time it will not be easy.
How will the HD unit cohort their patients to separate from others who are not considered direct contact?
How will they be quarantined at home for 2 weeks as they need to come to the HD unit three times weekly. What happen when the PUIs who are subsequently identified develop symptoms which require admission to the hospital? How can the hospital take so many HD patients while they have COVID-19 but also regular HD treatments three times weekly?
Meanwhile, the close contacts have to be referred to the designated hospital for screening.
Next, the attention turns to the set of healthcare givers including specialists, medical officers and nurses.
How many will need to be screened and who will have to be quarantined and prevented from working during the two-week period.
What if the nurses are dedicated nurses in the HD unit? If they have to stay at home, who will provide HD treatments for the many patients who need the life saving treatment on regular basis.
To make it more complex, another private specialist hospital and their staffs were also included in the equation as one of the specialist doctor who had close contact with the infected HD patient had seen and managed patients in both the HD unit and the specialist hospital.
With so many direct contacts which took place between the specialist doctor and the patients and staffs in the private specialist hospital the chaos became magnified several fold and broader .
While the Malaysian public, through regular press briefings introduced as the MCO is in place , get access to the latest statistics on the number of new cases diagnosed , total number of cases, numbers by states, number of deaths, number of subjects screened, number of screening done and number of cases in which test are pending, they lack details which can be important.
1. What is the breakdown on the duration of turn around time (TAT) between specimen collection and the release of the validated result. What should be an ideal TAT and what can be done to achieve it.
2. Apart from age, gender, what are the other co morbidities among those who were positive and those who died.
3. Were there any patients with ESKD on dialysis and which hospital provide dialysis support for affected patients requiring admission.
4. Among those in ICUs how many required renal replacement therapy and what were the modalities used.
Some of these questions may not be raised by the media representative present at the press conference but they represent important quality and equity aspects of the services available in various parts of the country which may explain the different clinical outcome for various patients screened and admitted in different facilities (eg provision of CRRT vs Standard Hemodialysis in the ICUs for patients with Acute Kidney Injury).
Hospital Sg Buloh for example became the national referral and dedicated hospital for COVID-19.
It dealt with the first cases, the more severe and complex cases including those who required ventilation and dialysis support but no mortality is reported thus far coming from the cases managed there.
What are the gaps in facilities, expertise and services in the different facilities, districts and states beyond inadequately supplied PPEs which should be reported and addressed transparently?
Some of these questions should be considered and attempts to provide the answers will help not just the life of the unfortunate patients but offer the Malaysian public, their leaders and policy makers and importantly also for the heroic front liner and last liner healthcare workers, to understand what we all need to achieve, beyond getting the incident curve flattened out.