Disputes Arise Over Cambodia’s Killer Illness

By Mary Kozlovski

PHNOM PENH, Aug 17 2012 (IPS) - The deaths of dozens of Cambodian children in recent months from an initially undiagnosed disease has highlighted the difficult balancing act between informing the public and potentially provoking panic.

On Jul. 4 the country’s Ministry of Health and the World Health Organization jointly announced that they were investigating an “unknown disease” that had killed 61 out of 62 children infected since April.

“The unknown disease starts with high fever, followed by respiratory and/or neurologic symptoms with rapid deterioration of respiratory functions,” the statement said.

Just over a week later, the MOH and WHO said that the cause in most of the cases was a severe form of hand, foot and mouth disease (HFMD). A majority of 31 samples obtained tested positive for enterovirus 71 (EV-71), which causes HFMD.

The controversy came after Swiss paediatrician Dr Beat Richner, founder of the respected Kantha Bopha children’s hospitals, criticised the WHO on Jul. 8, accusing it of causing panic “for nothing”.

Richner, who had first alerted the government to the disease that was killing children admitted to his hospitals, was concerned about comments the WHO had given the news agency Reuters that he felt were “neither professional nor necessary.”

Richner wrote that the WHO had told the world there was a “new mystery killer disease in Cambodia.” He said he had flagged the possibility with health authorities that an enterovirus was the cause. In an additional message later posted on Facebook, Richner said the WHO in Cambodia should be closed.

Maria Concepcion Roces, an epidemiologist with WHO in Phnom Penh, told IPS that the agency generally preferred to have a diagnosis before releasing information, but in this case the media had approached the agency with enquiries.

“We then decided with the Ministry of Health (that) we must say something, so that people would not speculate,” she said, adding that the ministry had requested WHO’s assistance with the investigation after informing it of the illness on Jul. 1. “If we don’t say anything and people hear rumours, then I think that is what may cause panic.”

Dr Richner also pointed out that of more than 75,000 patients treated at Kantha Bopha outpatient stations in June, only 34 were hospitalised because of the illness in question, stating that on a public health level it was “not an alarming issue”. He cited dengue fever cases as a particular concern.

Richner could not be reached for further comment.

Duane Gubler, professor in the Emerging Infectious Diseases programme at Duke-NUS Graduate Medical School in Singapore, told IPS by email that the response to the EV-71 outbreak was a “higher priority” because the illness was initially undiagnosed.

“The MOH (Ministry of Health) and WHO were working blind at the time; the etiology of the outbreak was not known and there were fatalities,” he said. “Once the virus was identified, then the MOH can return to a normal public health response.”

Gubler said health agencies often communicated confidentially before making public announcements to ensure that accurate information was disseminated without sparking panic or overreaction.

He said the media often exacerbated such issues through “irresponsible reporting”.

“In such events, for the good of the public, the press should be provided accurate and up-to-date information so they can help public health officials inform the public and prevent panic,” Gubler said.

Possible outbreaks of infectious disease are a matter of concern in the region, which in the last decade has been hit with cases of severe acute respiratory syndrome (SARS) and A(H5N1), commonly known as avian influenza or bird flu. According to WHO figures, 21 people are known to have been infected with avian influenza in Cambodia since 2003, resulting in 19 deaths.

HFMD is a common infectious illness that often affects children, but there is no specific treatment for it. The WHO says symptoms can include fever, mouth sores and a rash with blisters on hands, feet and buttocks, and patients usually recover within a week. However, in some cases EV-71 can cause more serious, and potentially life-threatening, symptoms.

Sok Touch, director of the MOH’s communicable disease control department, told IPS it was “inevitable” that people would be concerned when details about such an illness were released, but insisted that keeping the public and other health authorities informed was crucial.

Shortly after the results of the investigation were announced last month, local media reported that Cambodian authorities had closed schools and kindergartens ahead of the mid-year vacation because of concerns about EV-71.

Sok Touch declined to comment on the decision to close the schools. The WHO’s Maria Concepcion Roces said that the agency did not make recommendations regarding school closures, and left such decisions up to individual states.

In a Jul. 27 update, the Ministry of Health and WHO said that 56 children of the original 61 investigated have died, and said the authorities had identified nine additional cases of severe EV-71 infection, resulting in three deaths, among 533 HFMD cases reported.

Duane Gubler agreed that there was particular sensitivity to potential outbreaks of infectious disease in the region because today’s “unprecedented urbanisation and globalisation” increases the likelihood that exotic pathogens will spread from rural to urban areas.

“This is why WHO is much more proactive about outbreaks such as the one in Cambodia that wasn’t immediately identified,” he said. “Rapidly spreading epidemics such as SARS can threaten global economic security.”