Dengue – don’t just blame the primary care doctors

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Do not blame the doctor for dengue

The Federation of Private Medical Practitioners’ Associations, Malaysia (FPMPAM) would like to issue the following comments in response to the comments from the Malaysian heath minister on Jan 28, 2015 that private doctors fail to detect symptoms of dengue early.

Our members in general practitioner (GP) and family clinics have noted increasing number of dengue cases presenting with differing clinical patterns since the year 2000. Our doctors have been on unrelenting high alert for dengue cases since the year 2000.

It should be clearly stated that existing commercially available test kits cannot confirm the diagnosis of dengue in the early stages of the disease. What is most important is a high index of suspicion for all cases and the proper use of the test at the appropriate time.

This decision is best left to the attending doctor, to advise on adequate fluid consumption, monitor the patient regularly for danger signs and to refer problematic cases with potential complications to hospitals for further management. This has been the standard operating procedure recommended by the Health Ministry.

It is thus not correct that private primary care doctors cannot diagnose dengue in more than 99 percent of cases as was reported.

The alternative is to direct private doctors to send all cases of clinically suspected dengue i.e., virtually all cases with febrile illness to the public hospitals for further screening and management. This will mean crippling the already overloaded hospital facilities.

The majority of dengue cases do not need hospital care. We would like to emphasise that our private GPs are adequately trained and equipped to diagnose and manage such cases of dengue and should be appreciated for their effort to manage this disease at the primary care level.

I’d like to highlight an important point.
In an undifferentiated viral fever in the early stages e.g. the first 1 or 2 days, the clinical management is essentially the same. It is difficult to pinpoint the type of virus on the 1st day of any viral illness and even the dengue combo kit is not infallible.
Most cases of dengue can be managed as an outpatient. The primary care doctor is trained to refer patients to hospitals for admission particularly when patients are more ill and when the “warning signs” are present:

Dengue_Classification

(image from MFP – Management of Dengue)

As for notification of dengue, it can be done on clinically suspected dengue and one doesn’t need to wait for confirmation by any test kit (there is a box to check if the case is “suspected” in the official notification form). The point is, GPs do notify (it is required by law). Whether or not it is notified on the 1st, 2nd, 3rd or 4th day of illness – does it really make a difference? Let me be frank here. Our public health system is swamped. An immediate public health inspection and response to every notification of dengue is going to be unlikely in the face of an upsurge in numbers of dengue. We do need a coordinated public health effort involving everyone – the public, town councils, health office – in order to combat this menace. Just don’t lay the blame on GPs.

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