Be hygienic Malaysians

Proper handwashing is crucial to reduce the risk of transmitting all sorts of diseases.

DURING the H1N1 outbreak in 2009, it was noticeable that the health message of clean hands was taken seriously by healthcare facilities and the public. Many members of the public used the dispensers of hand sanitisers put up by the owners or tenants of healthcare facilities, offices, shopping complexes and other buildings.


It was then cool to keep one’s hands clean.

Many doctors and healthcare professionals had then hoped that the response to the then little known H1N1 virus would be translated into a habit.

With time, it was established that H1N1 was like any other flu for most individuals and like no other flu for some individuals. There was then a noticeable decline in the practice of keeping one’s hands clean. This is reflected in the reports of food poisoning and the high percentage of bacterial contamination of food sold since then.

Keeping one’s hands clean is a beneficial behaviour as many infections are spread by touch. This article is about the why, when and how of always keeping one’s hands clean.

A clean environment

There are various modes of transmission of organisms from one person to another.

Micro-organisms are present on everyone’s skin and body as well as surfaces in our surroundings. Direct physical contact between one person and another can lead to transmission of infections like respiratory viruses, hepatitis A and B, HIV and bacterial infections. The modes include shaking hands, touching, sexual intercourse, blood and other body fluids from a patient to a doctor or healthcare professional through skin lesions.

Micro-organisms like respiratory viruses and salmonella can be transmitted indirectly from one person to another through an intermediate, usually inanimate object. The modes include touching contaminated surfaces and sharing objects.

Droplet transmission involves the spread of micro-organisms like influenza through large particle droplets through the air when one person and another are in close proximity. The modes include talking, coughing and sneezing.

Airborne transmission involves the breathing in of micro-organisms like tuberculosis and legionella evaporated from droplets or within dust particles through the air within the same area or over a longer distance.

Micro-organisms can also be transmitted through common vehicles like water, food, medicines as well as shared syringes and needles among injecting drug users. These common vehicles can lead to the transmission of micro-organisms to many people.

The hands are the most common vehicle for the transmission of healthcare associated infections (HCAI), which has been defined by the Centre for Disease Control of the United States as “any infection associated with a medical or surgical intervention”.

HCAI is a major patient safety issue worldwide. It has been found to affect about 5 to 10% of patients in the developed world and double to 20 times more in developing countries. The incidence is higher in critical care units.

HCAI can lead to an increase in the severity of an illness, an increase in antimicrobial resistance, prolongation of the stay in a healthcare facility, long term disability, increased deaths and additional financial and personal costs for those affected and their families. The more ill a person is, the more likely he or she will be at risk of HCAI and its consequences.

Although HCAI involves patients and their caregivers and/or healthcare professionals, transmission of infections also occur between people with infections and their family and friends.

The sequence of events in the transmission of micro-organisms from an infected person to others is as follows:

  • Every person’s skin sheds off tissue containing micro-organisms all the time and they contaminate the hands directly or indirectly.
  • The micro-organisms also contaminate the surfaces in our surroundings.
  • The micro-organisms survive and multiply on the hands and the surfaces. The degree of contamination is influenced by the duration of exposure and the survival time of the micro-organisms, which is variable.
  • The hands remain contaminated unless there is action taken to ensure effective hand hygiene.
  • The micro-organisms are transmitted from one person to another through the contaminated hands.

As such, hand hygiene should be the concern of everyone whether they are sick or not. It is of particular importance in the sick, their caregivers and healthcare professionals.

Everyone needs to have clean hands to protect themselves and their environment from harmful micro-organisms. There is also a need for a person providing care to the sick, whether as a caregiver or healthcare professional, to have clean hands so that the patient is protected against harmful micro-organisms on the hands of the caregiver or the patient.

Planning for effectiveness

It is pertinent that the World Health Organization (WHO) launched its Global Patient Safety Challenge, “Clean Care is Safer Care” in October 2005, with the objective of reducing HCAI globally.

WHO’s decision was evidence based.

Hand hygiene has been found to reduce the risk of cross-transmission in schools, day care centres and in the community. (Luby SP et al Lancet, 2005, 366:225-233; Meadows E & Le Saux N BMC Public Health, 2004, 4:50). Hand hygiene promotion has reduced respiratory tract infections, diarrhoea and impetigo among children in the developing world.

The effectiveness of improved hand hygiene in reducing HCAI rates is well documented (Allegranzi B & Pittet D Journal of Hospital Infection, 2009 Aug 29). The reduction in HCAI rates in various reports has been as high as 70%.

Most reports also demonstrate a temporal relationship between improved hand hygiene and reduced infection and cross transmission rates as well as decreased incidence of drug resistant bacteria.

There is an association between infection and poor hand hygiene practices, of which improvement has assisted in the control of epidemics in healthcare facilities.

The cost effectiveness of hand hygiene is well documented. Pittet and his colleagues reported that the direct and indirect costs of a hand hygiene programme were US$1.40 (RM4.20) per patient admitted to a 2,600 bed hospital. A less than 1% reduction in HCAIs observed was attributable to improved hand hygiene practices, which would lead cost savings. (Lancet, 2000; 356:1307-1312.)

The National Patient Safety Agency of the United Kingdom made an economic analysis of its “Clean your hands” campaign in 2004. It noted that the economic benefits were financial and patient-related. The former included reduced costs to hospitals and general practitioners because of reduced HCAI, patients and caregivers, reduced compensation and increased economic productivity because of reduced work days lost.

The latter included reduced deaths and benefits associated with non-fatal HCAIs. It concluded that “the intervention will be cost-saving even if the reduction in HCAI rates were as low as 0.1%.”

It’s time

Hand hygiene is necessary before, during, and after preparing food. This is because although raw food may appear clean, it does not mean that it is safe.

It has been estimated that about 2.5 million bacteria are needed to make 250ml of water appear cloudy, while it takes about 15 to 20 bacteria to cause illness.

Cleanliness involves washing the hands before handling food and often during its preparation, washing and sanitising all utensils and surfaces used for food preparation, and protecting the food and kitchen from pests or animals.

Clean hands are needed before eating food, especially for those who eat with their hands. Harmful micro-organisms are spread when contaminated hands touch food items which are then consumed by others.

Clean hands are needed before and after caring for someone who is sick. Harmful micro-organisms are spread from the sick to their caregivers and/or healthcare professionals and vice versa, through the contaminated hands of caregivers and/or healthcare professionals.

Hand hygiene is vital before and after touching a patient; before handling an invasive device for patient care, regardless of whether or not gloves are used; after contact with body fluids or excretions, mucous membranes, non-intact skin, or wound dressings; if moving from a contaminated body site to another body site during care of the same patient; after contact with inanimate surfaces and objects in the immediate vicinity of the patient; after removing sterile or non-sterile gloves; and before handling medicines.

Hand hygiene is necessary after going to the toilet or after changing diapers or cleaning up a child who has used the toilet. This will prevent contamination of the hands by excretory materials.

Hand hygiene is necessary after blowing the nose, coughing, or sneezing to prevent contamination of the hands and surrounding surfaces by micro-organisms which can be harmful to others.

Hand hygiene is also necessary after touching an animal, animal waste or garbage, all of which contain micro-organisms which can be harmful to humans.

The mechanics of washing

An effective way of reducing micro-organisms growth is to wash the hands with soap and running cold or warm water for at least 40 to 60 seconds, especially when the hands are dirty or exposed to body fluids or after going to the toilet.

Liquid, bar or powdered soap can be used. When bar soap is used, the bars have to be placed such that there is drainage so that the bars will dry.

The hands should be rubbed together to make a lather and scrubbed well.

If there is no water and soap, a hand sanitiser containing at least 60% alcohol can be used. These sanitisers can reduce the number of micro-organisms in certain instances but they cannot get rid of all types of micro-organisms.

They are ineffective when the hands are obviously dirty. The hands have to be rubbed for 20 to 30 seconds.

Soap and alcohol-based hand sanitiser cannot be used together. It is important to adhere to the manufacturers’ recommendations on the use of soap and hand sanitisers, as well as the cleansing and refilling of the dispensers.

The need for hand hygiene by washing with soap or by using alcohol-based hand sanitsers is not replaced by the use of gloves, which are worn when there is likelihood of contact with blood or body fluids, mucous membranes, non-intact skin or potentially infectious materials.

There are techniques for the wearing and removal of gloves, which should be removed to perform hand hygiene when an indication occurs.

The same pair of gloves cannot be used for the care of more than one person or to touch a contaminated site of one person followed by another site of the body. Gloves should not be reused.

Hand lotions or creams that reduce the likelihood of contact dermatitis associated with hand washing or rubbing should be made available for healthcare professionals.

We all benefit

Hand hygiene has benefits for the well, the sick and their carers. Although clean hands do not totally eliminate the transmission of infection, the evidence is that it certainly reduces the incidence considerably.

Strict adherence to hand hygiene will go a long way in reducing infections and healthcare expenditures as well as improving the health status of every person.


Dr Milton Lum is a member of the board of Medical Defence Malaysia. This article is not intended to replace, dictate or define evaluation by a qualified doctor. The views expressed do not represent that of any organisation the writer is associated with.

I’m gonna jump

The are several factors that increase the risk of a person committing suicide.

EVERYONE’S life has its ups and downs, with feelings and emotions accompanying many of these situations. Most people adapt and cope with the downs. However, there are some who are so overcome with these emotions that they take their own life.

Suicide is an individual’s intentional act of ending his or her life.

Many suicide attempts are preceded by a history of self-harm, in which there is deliberate injury that a person inflicts on his or her body. This does not mean that the person who self-harms wants to commit suicide, but is an effort by the person to cope with intense emotions.


However, self-harm is an indication that the person needs immediate assistance.

Suicide is a common cause of death in young people worldwide. According to the National Health and Morbidity Survey 2006, there was a 6.3% rate of acute suicidal ideation, and 25.8% of chronic suicidal ideation. The highest prevalence rate of suicidal ideation of 11% was found in those aged between 16 and 24 years.

The National Suicide Registry Malaysia (NSRM) 2008 report stated there were 290 suicides in that year, of which 219 were men and 71 women, with Chinese comprising 53.5%, Indians 27.3%, and Malays 13.9%.

The youngest suicide victim was 12 years, while the oldest was 83 years. The NSRM estimated that there were 425 suicides between January and August 2010, averaging 60 per month, ie two daily.

It is estimated that the suicide rate is similar to that of the United States.

Although women are more likely to attempt suicide and other self-harm behaviour, it is the men who are more likely to succeed in suicide. The suicide rate in men in many countries is about three times that of women.

Risk factors

The reasons why some people commit suicide while others in similar situations do not, have not been determined. However, there are some factors that increase the risk of suicide.

Genetics is believed to be a risk factor as suicide has been found to be more common in certain families. There are several genetic mutations reported that may alter the chemicals in the brain, increasing the vulnerability to suicidal thoughts and behaviour. However, no specific gene for suicide has been identified.

Mental health conditions are the most significant risk factor, particularly serious and chronic mental health conditions. It has been estimated that about 90% of people who commit or attempt suicide have a mental health condition.

Severe depression is associated with misery and hopelessness – there is a 20-fold increase in the likelihood of attempted suicide than the general population.

Sufferers of bipolar disorder alternate between extreme joy to severe depression. About a third of these sufferers attempt suicide, and about 10% commit suicide.

Patients with schizophrenia are unable to think logically, and have difficulty differentiating between real and unreal experiences, with about 5% committing suicide. The risk is greatest when the diagnosis is made, but with the passage of time, they are better able to cope with their situation.

Anorexia nervosa is a condition in which anxiety about body weight leads to extreme efforts at limiting food consumption. About a fifth of anorexics will attempt suicide.

Patients with borderline personality disorder have altered thinking, unstable emotions, impulsive behaviour and unstable relationships. About half of these sufferers will attempt suicide, with an increased risk in those who were sexually abused in childhood.

It is believed that a combination of other factors increases the risk of suicide. These factors may or may not be significant, depending on the person’s vulnerability at the point in time. They include:

  • History of a recent traumatic experience, eg end of a relationship, bullying, loss of job, bereavement.
  • History of a traumatic experience in childhood, eg sexual or physical abuse, bereavement, parental neglect.
  • A parent with a serious mental health condition, eg severe depression, bipolar disorder, schizophrenia, or who committed suicide.
  • A previous attempt at suicide.
  • Social isolation, with few family members or friends.
  • Misuse or abuse of drugs and alcohol .
  • Unemployment or poor job satisfaction or security.
  • Debt.
  • Occupations which permit access to the means to attempt suicide, eg doctor, nurse, pharmacist, planter.


Danger signs

There are warning signs that indicate that a person is suicidal. They include talking or writing about death or suicide threats to injure or kill himself or herself, and actively seeking methods of committing suicide, eg stockpiling medicines, particularly sleeping pills, and/or pills used to treat serious mental conditions.

Other warning signs include:

  • Complaints, talk or behaviour that indicate hopelessness or a meaningless life.
  • Loss of interest in personal appearance, eg poor dressing, cessation of use of make-up.
  • Reckless or risky behaviour without concern for the consequences.
  • Sudden mood changes, anxiety, agitation.
  • Increased withdrawal from interactions with family members and friends.
  • Insomnia or sleeping all the time.
  • Abuse or misuse of drugs or alcohol.
  • Putting their affairs in order.

When warning signs are noticed, it would be useful to encourage the affected person to talk about it and to listen attentively. One should listen to what the person has to say to let them know that there is someone who cares about them.

A non-judgemental manner and empathy are essential. One should not influence what is said, but rather, facilitate honest and frank conversation.

Any questions raised by the listener have to be open-ended, and not end the conversation.

At the same time, the person’s doctor or nurse should be contacted. If it is not possible to do so, the accident and emergency department of the nearest hospital should be contacted as to how to get professional help for the affected person. If one assesses that the affected person has a high risk of dying by suicide before the arrival of professional help, one should contact the nearest ambulance service.

At the same time, any possible means of suicide should be removed from the immediate environment of the affected person. This would include medicines, household chemicals, sharp objects, etc.

Providing care to a suicidal person is stressful and distressing, and it can impact upon the carer’s mental health. Professional help may be required to address the carer’s emotions after the event.

Preventing suicide

Mental health is no different from physical health. Measures can be taken to improve mental health so that one is stronger emotionally and better able to cope with the downside of life, thereby reducing the risk of developing mental health conditions like depression.

Exercise is effective in the management of depression. Physical activity reduces stress and anxiety, improves mood, and promotes the release of brain chemicals called endorphins, which makes one “feel good”.

A healthy diet not only provides protection against physical health problems, but may also be vital in maintaining mental health.

Avoidance of social isolation is an important measure as it is a risk factor for suicide. Having friends is beneficial for mental health. If there is individual difficulty in making friends, you should consider joining a local activity group or support group. There is evidence that people involved in providing assistance to others through voluntary or charity organisations are mentally healthier than the general population.

Having a positive attitude is vital as persistent negative thoughts increase the risk of isolation. Cognitive behaviour therapy (CBT) is a type of talking treatment that assists in the management of problems by changing the thoughts and actions of the affected person.

Many people use drugs to help them cope with life’s problems. Their misuse or abuse may lead to more problems and increases the risk of developing serious mental conditions like depression.

Even recreational drugs like marijuana, which is perceived to be less harmful, increase the risk of depression and schizophrenia in some people.

Many people use alcohol to help them cope with life’s problems. Its misuse or abuse may lead to more problems and increases the risk of depression. It would be prudent to avoid exceeding the recommended daily alcohol consumption limits – ie three to four units for men and two to three units for women. A unit is the equivalent of about half a pint of normal strength lager, a small glass of wine, or 25ml of spirits.

A consultation with your regular doctor would be helpful if there are problems with drug usage or alcohol consumption.

However, the evidence is that an effective preventive strategy is to educate doctors on how to recognise and treat depression, and restricting access to lethal methods of suicide. Another promising strategy is to train particular groups of people on how to identify those at risk and refer them for treatment.

Support groups provide counselling and practical advice to people who are depressed, or have suicidal thoughts. The local support group are the Befrienders and their contact details are 95, Jalan Templer, Petaling Jaya 46990 (Telephone: 03 7956 8144 or 03 7956 8145; email:

If you do not like the idea of talking to someone on a helpline, you can talk to a family member, trusted friend, doctor or religious leader. You should also consult your doctor, who can prescribe treatment for mental health conditions.


Dr Milton Lum is a member of the board of Medical Defence Malaysia. This article is not intended to replace, dictate or define evaluation by a qualified doctor. The views expressed do not represent that of any organisation the writer is associated with.

Hard to learn

Although dyslexia is considered a learning disorder, there is no relationship between dyslexia and intelligence.

SOME people have a learning disability that leads to difficulty in learning and using certain skills. The skills that are usually affected are reading, writing, listening, speaking, reasoning, and doing mathematics.

The terms used for these disabilities are dyslexia, which refers to difficulties in reading and spelling; dysgraphia, which refers to difficulties in writing; and dyscalculia, which refer to difficulties in doing mathematics.

This article is about dyslexia, which is derived from the Greek works, dys (difficulty), and lexia (use of words). The symptoms range from the very mild to the very severe. People with dyslexia have difficulties with phonemic awareness, verbal memory and verbal memory speed.


Phonemic (or phonological) awareness is the ability to learn how speech sounds make up words, connecting the sounds to alphabet letters, and learning how to blend the sounds into words. Changes in the sounds lead to different words with different meaning. This ability is believed to be crucial in early reading and spelling development.

Verbal memory is the ability to remember a sequence of verbal information for a short time. Verbal processing speed is the time taken to recognise and process familiar verbal information, e.g. this speed is the time taken to recognise the letters, A, S, E, A and N, process it, and then realise that it refers to the Association of South East Asian Nations. Although dyslexia is considered a learning disorder, there is no relationship between dyslexia and intelligence. Dyslexia has been defined well by Shaywitz, who stated that, “Dyslexia is a reading difficulty in a child or adult who otherwise has good intelligence, strong motivation and adequate schooling … Dyslexia reflects a problem within the language system in the brain.”

Dyslexia is reported to affect about 10% of schoolchildren, with about 4% having severe difficulties that affect their learning ability in school. The incidence in males is estimated to be 1.5 to three times more than that in females. It affects all ethnic groups.

Roots of dyslexia

Dyslexia is a genetic condition. However, there are various theories about the causes.

It occurs in certain families. It is estimated that a child of a dyslexic has a 40% to 60% chance of developing the condition. If an identical twin has the condition, it is very likely that the other twin would also have the condition.

Scientists have detected genes that may lead to dyslexia, but their effects on the brain have yet to be elucidated.

The phonological processing impairment theory is believed by many to explain how dyslexia affects reading and writing. The ability to understand spoken language is an innate capacity of the brain, which recognises a word as a whole and does not register it by the units of sound that constitute a word (phonemes).

However, reading and writing requires the ability to recognise the letters in a word, identify from the letters the phonemes, and then bring them together to form a word. This process, which is termed phonological processing, is believed to be impaired in dyslexics.

There is evidence from magnetic resonance imaging (MRI) that the part of the brain (left hemisphere) involved in producing, analysing and identifying written words demonstrate less activity in dyslexics when they read. This may impact upon phonological processing.

MRI has also shown that the activity in the cerebellum of dyslexics is different from those without the condition. The cerebellum, which is found at the lower back of the brain, is believed to be crucial to the processing of language, coordination and assessment of time. This may explain why dyslexics have difficulties with coordination and time management.

Distinctive features

There is individual variation in the features of dyslexia. Each affected person would have distinctive features.

The features in a pre-school child include delayed speech development when compared to children of the same age; speech problems, like an inability to pronounce long words; problems expressing spoken language, like an inability to remember the right word to use; lack of understanding or appreciation of words that rhyme; or lack of interest in learning the letters of the alphabet.

It is not always possible to detect dyslexia in a pre-school child.

The features in the early school years include problems learning the names and sounds of letters, erratic spelling, problems copying written language, and poor phonological awareness, i.e. the ability to recognise that words are comprised of smaller sound units (phonemes) and new words can be created by altering the phonemes.

The child may also have difficulty in making sense of unfamiliar words by considering smaller words or collection of letters.

The features in the later primary school years include problems with spelling, problems understanding and recognising new words, and slow reading speed.

The features in secondary school include problems with reading fluency, slow writing speed, and problems expressing knowledge in writing.

Some dyslexics reach adulthood without the diagnosis ever being made. Their features include avoidance of reading and writing and hiding these difficulties from others, reliance on memory and verbal skills instead of reading and writing, poor spelling, and poor time management.

Dyslexia is associated with poor numerical skills, poor short term memory, poor concentration, poor time and organisational management as well as problems with physical co-ordination.

The earlier dyslexia is diagnosed, the more likely its management will be effective.

If a child has difficulties with reading and writing, a discussion with the teaching staff and a consultation with the family doctor would be helpful. The latter would exclude health problems which affect the child’s ability to read and write, e.g. vision problems, poor hearing, and other conditions like attention deficit hyperactivity disorder. The former would help in a review of the teaching methodology and provide alternative approaches and support, which is helpful for many children, including those with mild or moderate dyslexia.

If the problem persists despite the above, an assessment by an educational psychologist would be advisable. The latter is a specialist who assists children with problems in their educational progress because of emotional, psychological, cognitive (learning), or behavioural factors. This can be challenging as there are not many educational psychologists available in the country.

Alternatively, assistance can be sought from the Dyslexia Association of Malaysia, which has centres in Peninsular Malaysia. Its contact details are 6, Persiaran Kuantan, Off Jalan Setapak, 53200 Kuala Lumpur (Tel: 03-4025-5109).

The assessment includes an evaluation of the child’s reading and writing abilities as well as other skills like vocabulary, memory, reasoning, language development, processing speed of visual and sound information, organisational skills, and approaches to learning.

A diagnosis of dyslexia is made if the child’s reading and writing skills are poor despite appropriate teaching methodology and the child’s logic and verbal skills are unaffected.

Adults can also have similar assessments done.

Treating dyslexia

There is currently no cure for dyslexia. However, there are many interventions that can assist dyslexics. The degree and type of intervention is determined by the severity of the problems.

Interventions before a child goes to school are effective in achieving long term improvements in the condition. There is evidence that interventions which improve the ability to identify and process sounds (phonological skills) are effective.

These interventions, which are called phonics, concentrate on recognition and identification of sounds in spoken words (phonemic awareness) and instruction on phonics, spelling, writing, vocabulary, comprehension, and fluency.

There is evidence that effective methods of teaching phonics to dyslexics have certain features:

● Teaching is structured, with gradual increase based on what has been learnt previously.

● Use of different senses.

● Reinforcement with regular practice.

● Development of other useful skills.

● Recognition that there are different learning methods and approaches and then selecting the appropriate one for different situations.

● Breaking down the dyslexic’s emotional barriers, like anxiety and frustration, with empathy, encouragement, and promotion of the dyslexic’s self-esteem.

Many older children find the use of educational software applications useful rather than text or exercise books.

Similar approaches are useful in adult dyslexics.

In a nutshell

It is useful to remember that about 95% of dyslexic children respond well to educational interventions, with reasonable to good progress in reading and writing. About 5% continue to experience difficulties and would need more rigorous and long-term support.

It must be emphasised that although dyslexic children encounter daily challenges, even those with severe dyslexia can go on to have full and productive lives.


Dr Milton Lum is a member of the board of Medical Defence Malaysia. This article is not intended to replace, dictate or define evaluation by a qualified doctor. The views expressed do not represent that of any organization the writer is associated with.

When sepsis strikes

Sepsis is a potentially life-threatening condition triggered by an infection, and must be detected and treated early.

Everyone suffers from infections from time to time. Various parts of the body can be involved, for example, the respiratory tract, skin and urinary tract.

The organisms are usually bacteria and viruses, but may occasionally be parasites or fungi.

The body’s response to an infection is to limit it to one site. White blood cells travel to the infection site, and a series of reactions occur to fight the infection and prevent its spread.

The process, called inflammation, is aimed at removing the harmful organisms and damaged cells, and start the healing process.

Inflammation can be acute or chronic. The former lasts a few days, though sometimes, a few weeks. The latter can last several months, or even, years, and is due to failure to eliminate the cause of the acute inflammation, or it could be due to a chronic persistent microbe of low intensity. An example of the former is acute upper respiratory tract infection, and the latter, tuberculosis.

When the immune system is weak or the infection is virulent, the infection spreads through the bloodstream to other parts of the body and causes widespread inflammation.

The body’s response injures its own tissues and organs. There may be a marked decrease in blood pressure that affects oxygen transport to vital organs like the heart, kidneys and brain. If untreated or treated inadequately, sepsis leads to multiple organ failure and death.

Infections associated with sepsis are infections of the lung, urinary tract, gallbladder, abdomen, pelvis, skin, and even, flu, in some cases.

The most common infection sites that lead to sepsis are the lungs, urinary tract, abdomen and pelvis.

However, there are instances where the source and cause of the sepsis cannot be identified.

According to the Malaysian Registry of Intensive Care, head injury, sepsis and community-acquired pneumonia were the three most common diagnoses leading to admission to intensive care units (ICU) in Health Ministry hospitals in 2011.

The in-hospital mortality rates of these patients were 25.2%, 58.9% and 40.6% respectively.

Risk factors

Everyone is at risk of sepsis. Some patients with sepsis do not require hospitalisation, although they feel ill. When sepsis is severe, immediate hospitalisation is necessary.

Sepsis is more common in those at risk – the very young and very old; the pregnant; those who have chronic conditions such as diabetes; those who just had surgery, accidental injuries and/or with invasive devices such as drips, catheters and ventilators; those whose immunity are weakened, such as HIV patients or those on treatment that weakens the immunity (long-term steroids, cancer chemotherapy); and those who are hospitalised for some other condition.

Hospital-associated infections are more serious, as many of the bacteria are resistant to many commonly-used antibiotics.

Managing sepsis

The features of sepsis include fever, chills, shivering, tiredness, poor appetite, rapid heart rate and rapid breathing.

The features of severe sepsis, which is life-threatening, include difficulty breathing; abnormal heart function; cold, clammy skin; abrupt change in mental state (confusion, disorientation); slurred speech; loss of consciousness; markedly decreased urine output; and decreased platelets.

The blood pressure in septic shock is very low and does not respond adequately to fluid replacement.

The diagnosis of sepsis is clinical, and the tests include that of blood and body fluids, such as urine, wound secretions, respiratory secretions and stool; imaging, including x-ray, ultrasound, computerized tomography (CT) scan; and kidney, heart and lung function tests.

Early diagnosis is essential to determine the type of infection, its location, and its impact on body functions.

Early treatment is necessary to stop the sepsis from progressing, reduce damage and decrease the risk of death. Treatment is dependent on the site and cause of the initial infection, the organ affected and the damage caused.

Severe sepsis or septic shock can only be treated in a hospital and may require admission to the ICU. This is because the chances of death in severe sepsis and septic shock is about four and six in every 10 affected persons respectively.

The mainstay of treatment for sepsis, severe sepsis or septic shock is antimicrobials upon diagnosis, even before the infectious agent is identified.

Initially, broad-spectrum antimicrobials, which are effective against a variety of organisms, are administered intravenously.

After getting the blood results, the antimicrobials may be changed to one that is more appropriate to the specific cause.

Although antibiotics are not effective against viruses, parasites or fungi, it is likely that they will be started anyway because it would be too dangerous to delay treatment.

Once the specific cause is identified, the appropriate antimicrobial will be given.

Antiviral agents may be given at the outset if there is strong suspicion that it is the cause of the sepsis.

The source of the infection, when identified, will be treated. Collections of pus will be drained. Surgery may be needed to remove pus and infected tissue.

Oxygen is administered through a mask or tubes in the nostrils if blood oxygen levels are low.

Those who have severe difficulty breathing would have a tube inserted into their trachea that is connected to a machine that helps breathing mechanically (i.e. a ventilator).

Medicines called vasopressors are prescribed for low blood pressure to help increase it by stimulating the muscles that pump blood around the body and narrowing or constricting blood vessels.

Extra fluids may also be given intravenously to help increase blood pressure.

Sufficient intake of food and liquids is essential. The former is done by inserting a thin tube up the nose and down into the stomach, or by inserting a drip to provide food and fluids.

Intravenous fluids are usually given in severe sepsis or septic shock to prevent dehydration and kidney failure. A catheter will be inserted into the bladder to monitor urinary output so that renal failure can be detected early.

Painkillers may be needed. Medicines to keep the patient drowsy or asleep may be prescribed to ensure sufficient rest and make the patient more comfortable.

Other treatments that could be instituted include blood transfusion, steroids, insulin and dialysis for impaired kidney function.

The duration of treatment depends on each patient’s individual circumstances.

It is advisable for anyone with features of an infection to seek medical attention, particularly if there are risk factors.

Anyone who develops features of sepsis after surgery, hospitalisation or an infection is advised to seek immediate medical care.

Early diagnosis and treatment will lead to full recovery. Late diagnosis and treatment may lead to disability, and even, death.

Dr Milton Lum is a member of the board of Medical Defence Malaysia. The views expressed do not represent that of any organisation the writer is associated with.


Shingles is a result of the same virus that causes chickenpox.

Shingles or herpes zoster (HZ), which is also known as the “snake” in local vernacular, is an infection of a nerve and the surrounding skin by the varicella-zoster virus (VZV), which also causes chickenpox.

After a chickenpox infection, VZV does not disappear but remains inactive in the body. The virus is reactivated when the body’s immunity is weakened, e.g. increasing age, stress, chemotherapy for cancer, HIV/AIDS, recent organ or bone marrow transplant.

HZ cannot be transmitted to adults who have had chickenpox before. However, it is possible for someone who has not had chickenpox previously to get infected from direct contact with fluid from the blisters of a person who has shingles, as they contain live viral particles.

When the blisters have dried and formed scabs, the sufferer is no longer infectious. This usually takes 10 to 14 days.

A shingles attack usually lasts from two to four weeks, with the main symptoms being pain followed by a rash. It can affect any part of the body, with the chest and abdomen the most common areas.

Some may experience early symptoms, which occur a few days before the painful rash. They include a headache; burning, tingling, numbness or itchiness of the skin in the affected area; feeling unwell; and fever.

Eventually, most have a localised band of pain. The affected skin is usually tender to the touch. The pain usually occurs a few days before the rash appears, and can remain for days or weeks after the rash disappears.

The pain is more severe and lasts longer in the elderly.

The rash usually appears on one side of the body on the skin area supplied by an affected nerve. It appears as red blotches initially, and then develops into itchy blisters similar to those in chickenpox.

The blisters then flatten, dry out and turn yellowish. Scabs are formed where the blisters used to be, with slight scarring. Complete healing of the rash takes two to four weeks.

Sometimes, complications occur, especially if the one affected is older or immunity is weakened. The complications involve the nerves, skin, eyes and other organs.

Post-herpetic neuralgia (PHN) is the most common complication. It has been estimated that one in five HZ sufferers above the age of 50 years develop PHN. The pain may be constant or intermittent, burning, aching, throbbing, stabbing or shooting.

PHN sometimes take about three to six months to resolve, and may last for years and become permanent. It is more common and severe in senior citizens.

If the eyes are affected, the complications include ulcers and permanent scarring of its surface (cornea); increased pressure inside the eye (glaucoma); and inflammation of the eye and optic nerve, which connects the eye to the brain.

Ramsay Hunt syndrome, which is due to HZ infection of certain nerves in the head, is rare. It causes earache, hearing loss, dizziness, a feeling that the body or environment is moving (vertigo), hearing sounds from inside the body (tinnitus), loss of taste and facial paralysis.

Other rare complications include infections of the lung (pneumonia), liver (hepatitis), brain (encephalitis), spinal cord (myelitis) or the membranes surrounding the brain and spinal cord (meningitis).

Although HZ is rarely life threatening, it has been estimated that it is fatal in about one in every 1,000 cases in adults above 70 years.

There is no cure for HZ. However, early treatment may reduce its severity and the risk of complications.

Medicines to relieve the pain are usually prescribed.

Antiviral medicines are also prescribed to some patients for seven to 10 days. Although these medicines cannot kill HZ, they stop it from multiplying. This reduces the severity and duration of the attack and prevent complications like PHN.

The medicines are most effective when taken within 72 hours of the rash appearing. They may be taken within a week of the rash appearing in those who are at risk of severe HZ or its complications, i.e. those above 50 years, HZ affecting the eyes, moderate to severe pain or rash, and weakened immunity.

A vaccine against HZ recently become available. Studies have shown that the vaccine reduces the incidence of HZ and PHN; the severity of acute pain; and HZ’s interference with activities of daily living in adults above 50.

The vaccine has been reported to be efficacious for up to 10 years. The incidence of serious side effects is less than 0.1%.

The vaccine has been recommended for adults above 60 years, and may also be prescribed for adults above 50 years.

If you have a HZ rash, avoid swimming, contact sports or sharing towels. This will prevent spread to anyone who has not had chickenpox, which is especially dangerous for the pregnant, infants less than a year, and those with weakened immune system.

If the rash is oozing fluid, it is advisable to avoid work or school.

When the blisters have dried and formed scabs, the sufferer is no longer infectious and does not need to avoid anyone.

Dr Milton Lum is a member of the board of Medical Defence Malaysia. This article is not intended to replace, dictate or define evaluation by a qualified doctor. The views expressed do not represent that of any organisation that the writer is associated with.

What is Obstructive Sleep Apnea (OSA)

Good sleep is essential to ensure an efficient and effective performance of your daily activities. A normal adult requires an average of 8 hours of sleep per day. That is one third of our lifetime!


Sleep apnea is a condition characterized by multiple brief interruptions or cessation of breathing during sleep. It is increased with obesity and age and estimated to affect 5% of the adult population. The commonest form of obstructive sleep apnea (OSA).



Apnea can occur when excess tissue in the upper airway, such as abnormally large tonsils, blocks the airway during sleep. Apnea can also occur when the tongue or throat muscle relax too much leading to the collapse/closure of the upper airway.


  • Loud snoring
  • Cessation of breathing during sleep (apnea)
  • Choking, gasping, snorting during sleep
  • Restless sleep
  • Excessive daytime sleepiness (Epiworth Sleepiness Scale)
  • Morning headache
  • Dry mouth
  • Poor concentration and short term memory
  • Decreased libido


  • Hypertension
  • Stroke
  • Ischemic heart disease
  • Gastro esophageal reflux disease
  • Depression
  • Diabetes mellitus
  • Increased risk of motor vehicle accidents in drivers


  1. You need to undergo a physical examination and assessment by a physician
  2. You would then undergo an overnight sleep study (polysomnography [PSG]). This can be performed either at your home or at a hospital.
  3. The PSG would provide your doctor with details of your sleep pattern, breathing disturbances and blood oxygen level. Treatment will depend on the severity of the condition. Most patients will require the use of a Continuous Positive Airway Pressure (CPAP) machine during sleep to relieve the obstruction and symptoms.

The Epworth Sleepiness Scale is a simple way of accessing the degree of sleepiness. The higher the score (>10), the greater the likelihood of you suffering from sleep apnea.
0 = would never doze
1 = slight chance of dozing
2 = moderate chance of dozing
3 = high chance of dozing

Rate yourself in these situation. Chances of dozing from scale of 0-3

  1. Sitting & Reading
  2. Watching TV
  3. Sitting, inactive in public places
  4. As a passenger in a car for an hour without a break
  5. Lying down to rest in the afternoon when circumstances permit
  6. Sitting & talking to someone
  7. Sitting quietly after lunch without alcohol
  8. In a car, while stopping for a few minutes in the traffic

Note: Not all people with OSA experience daytime sleepiness. If you did not score in the higher ranges but you have concerns about your sleep, talk to our Specialist. Our Consultant Physician, Dr. Lau Wee Ming specialises in Sleep Study. She is available by appointment on Wednesday and Saturday. For more information, please call 603 – 6141 8533. 

Understanding the different types of diabetes

The number of people afflicted by diabetes has risen significantly in recent years. What is your understanding of diabetes?

THE main sugar in the body is blood glucose, which comes from consumed food and is also made in the liver and muscles.

After a meal, blood glucose level rises. The cells in the pancreas, which is an organ in the abdomen, are stimulated to release a hormone called insulin into the bloodstream.

The insulin then attaches to the body’s cells and signals them to absorb glucose from the blood and use it for energy.

Sometimes, the body does not produce enough insulin, or the insulin does not function as it should. When this happens, glucose remains in the blood and does not reach the body’s cells. Its level rises, causing diabetes mellitus, which is a lifelong condition.

Many people have blood glucose levels above the normal range, but not high enough to be diagnosed as diabetes. This is a condition called pre-diabetes.

If the blood glucose level gets above the normal range, the risk of developing full-blown diabetes is increased.

It is important that diabetes is diagnosed and treated as early as possible because it will only worsen with time. If untreated or treated inadequately, it will cause multiple health problems.

According to the National Health and Morbidity Survey (NHMS) IV in 2011, the overall prevalence of diabetes was 15.2%. The prevalence was highest among Indians (24.9%), followed by the Malays (16.9%) and Chinese (13.8%). There were no gender differences.

The overall prevalence of known diabetes was 7.2%, and undiagnosed diabetes 8.0%. The prevalence of impaired fasting blood glucose was 4.9%.

The overall prevalence of diabetes among adults above 30 years rose from 8.3% in NHMS II in 1996 to 14.9% in NHMS III in 2006. This has significant implications for the healthcare delivery system.

Types of diabetes

There are two types of diabetes: type 1 and type 2.

Type 1 diabetes is caused by attacks of the body’s immune system on the pancreatic cells that produce insulin. Since no insulin is produced, the blood glucose is raised.

Type 1 diabetes is often called insulin-dependent diabetes. It usually develops before the age of 40 years, often when the sufferer is in the teens. Its incidence is a fraction of type 2 diabetes.

All type 1 diabetics require insulin for the rest of their lives. In addition, there has to be a healthy lifestyle to ensure that blood glucose remains within normal limits.

Type 2 diabetes is caused by insufficient production of insulin, or the failure of the body’s cells to respond to insulin. The latter is called insulin resistance. It usually develops after the age of 40 years and its incidence is about four to five times that of type 1 diabetes.

It is often associated with obesity. It is controlled by a healthy diet, regular exercise, and eventually, medicines – usually tablets. Medicines are often required at some stage because type 2 diabetes is a progressive condition.

Features of diabetes

The signs and symptoms of diabetes include feeling thirsty, hungry and/or tired; passing urine more often than usual, especially at night; weight loss without attempting to lose weight; loss of muscle bulk; feeling pins and needles in the feet; losing feeling in the feet; blurred vision; wounds that heal slowly; and itching around the genitalia or frequent fungal infections.

There may be no signs or symptoms in some people, or if there are symptoms, they are usually vague.

The only way to confirm a diagnosis of diabetes is to have a blood test.

There are two tests used to diagnose diabetes: fasting blood glucose and glucose tolerance test.

Fasting blood glucose is a reliable diagnostic test. A single blood sample is taken after an overnight fast. The normal levels are below 6.0 mmol/L. Levels above 7.0 mmol/L on two or more occasions is indicative of diabetes, and no other tests are needed.

A glucose tolerance test (GTT) is done after an overnight fast. Blood is taken for the fasting blood glucose, followed by consumption of 75g of glucose, with blood samples taken on two or four subsequent occasions within a period of up to two hours, to measure the blood glucose.

The levels rise and then fall rapidly in a non-diabetic. In a diabetic, it increases to a higher level than normal and does not fall as rapidly. The body’s response to a GTT may vary and requires interpretation by a doctor.

Blood tests are just part of the information required. The doctor will also consider the patient’s history and physical examination findings in planning the diabetic’s management.

Gestational diabetes

The placenta in a pregnant woman produces a hormone called human placental lactogen (HPL), which modifies maternal handling of carbohydrates and lipids as it makes the body less sensitive to insulin, thereby raising the mother’s blood glucose level.

HPL raises the blood glucose level so that the foetus gets enough nutrients from the extra glucose in the blood.

Another hormone, called human placental growth hormone, is also produced in pregnancy. It also ensures that the foetus gets enough nutrients by raising maternal blood glucose levels.

It is normal for maternal blood glucose levels to increase a bit during pregnancy because of the effect of the placental hormones.

However, sometimes, the increase is too high. This condition is called gestational diabetes. It usually develops between 14 and 28 weeks of pregnancy, and disappears after the baby is born.

Gestational diabetics are at increased risk of developing type 2 diabetes later in life.

It is more common in women who are above 25 years, overweight or obese, have a family history of diabetes, or who had gestational diabetes in a previous pregnancy.

Gestational diabetes could increase the risk of problems for the foetus, and also worsen type 1 diabetes. As such, it is important for a gestational diabetic to keep her blood glucose levels under control.

Dr Milton Lum is a member of the board of Medical Defence Malaysia. This article is not intended to replace, dictate or define evaluation by a qualified doctor. The views expressed do not represent that of any organisation the writer is associated with.

























既然连死你都不怕,又何必担心那些区区的治疗。妻子一针见血,当头棒喝:如果不治疗等于死亡,那就来场show hand,我们至少还有六成的机会。






如果您对以上的状况有任何疑问请咨询我们的手术专科医生, Dr Chong Shun Siang. 请拨电 03-61418533 以做预约。

The Heart in Menopause

Menopause does not cause cardiovascular disease. However, certain risk factors increase around the time of menopause, and this compounds the risk of heart disease.

CARDIOVASCULAR disease (CVD) is a term that describes any disease of the heart or blood vessels. It includes heart attack (myocardial infarction, MI), heart failure, high blood pressure (hypertension) and stroke. MI and strokes are usually caused by blocked arteries.

There is no shortage of focus on women’s worry about cancer, especially breast cancer. However, the reality is that there are more women who die from coronary heart disease (CHD) than from breast cancer.

Many women think that CHD is a man’s disease. It is not. CHD is the most common cause of death in women. About half of all deaths in women after the age of 50 years are due to some form of CVD.

The most common cause of death in women in Health Ministry hospitals is CVD, which comprises about 25 in 100 of all deaths as compared to that of all cancers, which comprise 11 in 100 of all deaths. More women die of CHD than stroke, with about 15 and 10 in 100 deaths respectively.

The misperception of the incidence of CVD in women has led to inadequate information and health promotion to the public; inadequate screening for risk factors; lower rates of diagnosis; and lower usage of appropriate medications and interventions for treating women with CVD.

The problem is compounded by the fact that the symptoms of CHD in women are often not typical, resulting in delay in diagnosis and treatment.

Another misperception is that CVD in women is less threatening than in men. It is not. In-hospital and early post-MI mortality in women (9%) is more than double that of men (4%). The mortality rate a year after an MI is about 32% higher in women than in men.

Likewise, after a stroke, women are more likely to die than men (16% vs 8%). Women survivors after a stroke have a poorer long term outcome and a lower quality of life.

Menopause and CVD

Women who have not reached the menopause have a much lower risk of CVD than men. The risk to a woman increases significantly after the menopause when the oestrogen levels fall so much so that the risk of MI is twice or thrice that of women of the same age who have not reached the menopause.

Within a decade after a woman reaches the menopause, her risk of CHD is the same as that of a man.

Women who reach the menopause before the age of 50 years, whether spontaneously or after removal of the ovaries, have an increased risk of CVD. The risk is mainly that of CHD, not stroke.

The extent to which lowered oestrogen levels may lead to an increase in CVD risk is still not well determined. There is on-going research into this aspect.

Risk factors

Menopause does not cause CVD. However, certain risk factors increase around the time of menopause, and conditions and habits like hypertension, diabetes and smoking increase the risks.

There are several cardiovascular risk factors. Some cannot be changed, but others can be controlled or modified to reduce the risk. The former include increasing age, family history and post-menopause, especially if the menopause is premature (below the age of 40 years).

The risk of CHD is increased if a woman’s father or brother had a heart attack before the age of 55 years; the mother or sister had a heart attack before the age of 65 years; the higher the number of family members with CHD; younger family members with CHD; or if a family member had a stroke.

The findings in the National Health and Morbidity Survey (NHMS) 2011 are worrying. Apart from the increase in cardiovascular risk factors since NHMS 2006 and 1996, many of the risk factors were undiagnosed or poorly controlled.

Excess weight, especially when it is 30% above ideal weight, increases the risk of CHD. Obesity is associated with physical inactivity and both contribute independently to an increased risk of CHD.

The NHMS 2011 reported that the prevalence of overweight and obesity was 29.4% and 15.1% respectively. Abdominal obesity (more than 80cm for women) was found in 43%. Women, Indians and people aged 50 to 69 years were at increased risk of abdominal obesity.

Hypertension increases the risk of MI and stroke. Every 7.5mmHg increase in diastolic blood pressure increases the risk of stroke by 46%. The likelihood of death from CHD, stroke and other CVDs is doubled with an increase in systolic blood pressure of 20mmHg.

Most studies have shown that before the age of 60 years, women have lower blood pressure than men. After the age of 60 years, women have a much steeper rise in systolic blood pressure.

The NHMS 2011 reported that the prevalence of hypertension in adults was 32.7%, with an increasing trend with age, ie from 8.1% in the 18-to-19 years age group to 74.1% in the 65-to-69 years age group.

There were no significant differences between males and females, and between the various ethnic groups.

Diabetes increases the risk of CVD. Women with diabetes have twice the risk of having an MI than those who are not diabetic. The risk of dying from an MI in diabetic women is two to five times that of non-diabetic women.

The NHMS 2011 reported that the prevalence of diabetes in adults was 15.2%, with an increasing trend with age, ie from 2.1% in the 18-to-19 years age group to 36.6% in the 65-to-69 years age group. There were no differences between males and females.

Women who have a family history of diabetes, diabetes when they were pregnant, are obese, or of Indian and/or Malay ethnicity, are at increased risk of diabetes.

Raised cholesterol levels (hypercholesterolaemia) increases fatty deposits on the inner walls of arteries (atherosclerosis), decreasing blood flow, and eventually blocking the artery entirely. If it affects an artery supplying the heart, an MI can occur. If it affects an artery supplying the brain, a stroke can occur.

The NHMS 2011 reported that the prevalence of hypercholesterolaemia in adults was 35%, with an increasing trend with age, ie from 11.3% in the 18-to-19 years age group to 57.2% in the 65-to-69 years age group. The prevalence was higher in females, Malays and Indians.

Bearing in mind that the prevalence of CVD is considerably less in menstruating women, this means that women after the menopause have an increased risk of CVD. This is because of the increase in total cholesterol and low density lipoproteins, which may exceed that of men of the same age, both of which increase risk.

Cigarette smokers, both males and females, have twice the risk of MI than non-smokers. This risk factor is dose-related, with consistently higher risks in women than men, and is independent of age.

Tobacco induces an unfavourable lipid profile, increases inflammation and “encourages” thrombosis. This results in menstruating women losing their “natural” protection against atherosclerosis.

The Global Tobacco Survey 2011 reported that one in four Malaysians smoke, with the vast majority being males. However, about four in 10 Malaysians are exposed to secondhand smoke at work and/or at home. The effects of secondhand smoke are not very different from smoking itself.

Physical inactivity is almost as important a risk factor as smoking because of decreased circulation and weight gain. CHD is almost twice as likely to affect the inactive, compared to those who exercise regularly.

The NHMS 2011 reported that 64.3% of Malaysian adults were active, with the most active in the 40-to-44 years age group, with a gradual decrease after that. Males were more active than females.

Reducing risks

A healthy lifestyle goes a long way in preventing and reducing the risk of CVD. The following lifestyle approaches and/or modifications may help in reducing and/or managing the various risk factors before, during and after the menopause.

The identification and management of CVD risk factors should be an integral component of the periodic health examinations of all women, in addition to their gynaecological and breast examinations.

Of all the cardiovascular risk factors, smoking cessation and avoidance of secondhand smoke has the greatest impact on saving lives.

When a woman ceases smoking, however much or long she has been smoking, her risk of CHD decreases by 50%.

Apart from that, there is a decreased risk of lung disease, including cancer, and many other conditions.

The maintenance of a healthy body weight goes a long way in decreasing the workload of the heart.

Activity and regular exercise improves heart function and reduces risk factors like hypertension and hypercholesterolaemia, maintains a healthy weight, and reduces stress.

A balanced diet that is high in grains, fish, fruits and vegetables, with adequate water, vitamins and minerals, but low in saturated and trans-fats contributes significantly to good health.

The intake of sweets and fatty food should be limited. Fat intake should be less than 30% of daily calories.

Medical conditions like hypertension, diabetes and hypercholesterolaemia have to be diagnosed, treated and controlled. As these are chronic conditions, it is essential that there is strict compliance with medical advice.

Dr Milton Lum – is a member of the board of Medical Defence Malaysia. This article is not intended to replace, dictate or define evaluation by a qualified doctor. The views expressed do not represent that of any organisation the writer is associated with.

Disclaimer: Nothing on this blog should be considered or used as a substitute for medical advice, diagnosis or treatment. Blog visitors with personal health or medical questions should consult their health care provider.

Tips to consider for Haze

Haze is back. As the thick smoke drowns certain places in Klang Valley, the public have been advised to minimise their activities outdoors and take in adequate fluids.


  1. If you must go out, you should wear a mask. A good one – a surgical mask – would be fine.
  2. Drink adequate fluid to ensure that the lining of the nose and respiratory airways were well hydrated to make them less susceptible to irritation.
  3. For the eyes, the haze can cause irritation, conjunctivitis and also secondary bacterial infection through rubbing. Those who wear contact lenses should ensure optimum hygiene of their lenses.
  4. Blocked nose is quite a common problem but it can cause worsening symptoms for people with pre-existing rhinitis and sinusitis. Sore throats and coughs could result from the haze but it could cause even more problems for patients with a history of asthma.

You should seek medical help immediately should you face any problems.