For a physician in Malaysia, Dengue is considered as a bread and butter disease. Since Dengue was first discovered in Malaysia in early 1900, it had claimed many lives. Unfortunately, to date, there is NO cure for this disease.
The current Dengue epidemic/outbreak, which started almost 11 months ago, somewhere in April 2013, is one of the longest and most disastrous episodes I have ever seen during my 17 years of service. I have never seen such a long epidemic before and it looks like there is no end coming. Unfortunately, our public who screams when they hear about 3-4 H1N1 cases or Hand Foot Mouth syndrome seems not to be bothered about Dengue. They take it very lightly as though it is a non-fatal disease. For the year 2013, Dengue had claimed almost 94 lives. The number has reached 17 deaths in just 37 days of this year! Remember, majority of these patients are young and healthy individuals. JB hospital is having 1 death every week since November 2013!!
Where are we going wrong? It is a preventable disease and a holistic approach is needed. Our public health officers seem to be overloaded with this epidemic, so much so, they do not even come and interview any dengue cases in the wards anymore. Personally, I feel it is of no value. As long as they are aware the number of patients and where they are from, actions should be taken. Unfortunately, I feel that we are losing the battle. We are still deploying the same strategy since the last 50 years or so, which clearly has failed to control the disease this time around! The actions taken also seem to be rather slow due to shortage of manpower and lack of budget. What is the point of notifying within 24hrs when no action is taken within 48 hours?
Opening “Klinik Kesihatans” up to 10pm is not going to solve any problems either. Our Health Minister announced before the Chinese New Year that KKs would be opened till 10pm in Dengue Hotspot areas to reduce the congestion at Government Hospital emergency departments (ER). I think the more important issue is to educate the public that emergency department is for emergencies and not for cold cases. In 2003, MOH introduced outpatient clinics in Emergency Department with a rate of RM 40/hour. It was open to all doctors in the hospital. It failed. Subsequently, with the same reason of reducing ER patient load, most major KKs were asked to open till 9.30pm with a locum rate of RM 80/hour since 2008. Again, did this reduce the ER department patient load? The answer is NO. What we need is “public-private” integration, which will make our GPs as part of the primary health care system supported by a National Health Financing Scheme. This is what 1Care “suppose” to do but due to the current political situation, it has been postponed once again.
Now, with the excuse of Dengue, all KKs in hotspot areas are being asked to open till 10pm. Likely, even after this epidemic settles (hopefully), the opening hours of these clinics will remain, with the excuse of “ receiving good response from the public” as the 1Malaysia clinics supposedly did. The GPs nearby these clinics will definitely be affected. Eventually, MOs in KKs will be asked to work shift duties in order for KKM not to pay the “overtime allowance” of RM 80/hour. A pilot project of shift duty was conducted in KK PD last year. With close to 15 MOs in major KKs, it is not impossible to introduce shift duty. It will come, whether you like it or not. The only problem will be safety issues especially for female doctors and lack of support staffs despite having enough doctors.
What are we lacking in the preventive measures for Dengue? Firstly, we are still going after the Aedes mosquito after the incidence has already occurred (chasing from the back). Fogging and house inspection are only done almost 2-3 weeks after a case is reported in a particular area. By this time, the mosquito would have bitten hundreds more and would have laid hundreds of eggs all over the place. Should we think about detecting Aedes mosquito breeding area before it even starts to infect people with the Dengue Virus? During the 2003 outbreak, the then Johor state Pengarah Dr Prethapa Senan came up with a good idea. He decided to place a half cut mineral water bottle(small), on a wooden stick, pricked to the ground every few kilometers in a hotspot area. The health inspector will periodically check these bottles and immediate fogging and cleaning of the affected area with residence help is done, if an Aedes mosquito larva is detected. I found it rather interesting and although it involves a lot of work, it did bring down the number of dengue cases and the epidemic was over in just 6 months. Another issue that I always wonder is to what happened to discussions between MOH and researchers and academics from our universities?? I am sure many academics are involved in Dengue research and their expertise may be useful in controlling the disease.
As far as I am concerned, this Dengue outbreak should be considered as a National Disaster and a proper disaster plan should be developed for an all out war against Dengue. BUT I don’t see it happening from our political masters who are more interested in making “jokes” everyday in public. I don’t see any massive adverts to “scare” the people in the mainstream news, papers as well as alternative medias. This disaster should send chills through the spines of every resident so that the people will get frightened and do the needful to help the authorities. The Ministry should work hand in hand with the residence rather than working on their own. There is no point having mortality meeting after a death has occurred and only after that, inspections are done at the deceased house and surroundings to “prevent” another death!! Whatever said, Dengue is a public health issue and not a clinical issue.
There is NO cure for Dengue. IT is your own body’s immune system that kills you. That’s why the complications occur after the fever settles as your immune system starts to produce antibodies. It is also the reason why a secondary infection is more fatal than the primary infection. Many patients have the idea that early admission to hospital can cure their Dengue but frankly, the body cures itself. The only thing that doctors do is to keep you well hydrated and treat the complications, hoping that your body will over come it’s own immune system’s assault. Thus, there are also many Dengue cases that can be managed on an outpatient basis. The most important thing is that the patients need to be monitored by an experienced doctor. From my experience, when complications occur, many will die no matter what we as doctors do! You survive purely by luck!
Whether anyone realize it or not, this outbreak is a huge public health burden and draining huge amount of money. The insurance companies are bleeding billions of ringgits due to huge amount of admission to private hospitals. Many of these admissions may not be necessary but the fact remains that a patient can only use his medical card if he/she gets admitted. Thus, there are many unnecessary admission to private hospitals simply because the insurance companies do not cover outpatient treatment. I would suggest that insurance companies should make some adjustment during this outbreak to cover outpatient treatments of Dengue. This will definitely save a lot of cost for them.
It is rather sad to see young patients dying from a tiny virus and a mosquito. Many at times, we just watch this patient’s die right in front of our eyes as we stand helpless! May this epidemic come to an end soon………………
National dengue alert
Last updated on 6 February 2014 – 10:34pm
Annie Freeda Cruez
newsdesk@thesundaily.com
KUALA LUMPUR (Feb 6, 2014): The dengue fever and dengue hemorrhagic fever situation is worsening nationwide, with the number of cases hitting 9,453 and 17 deaths, all within the first 37 days of this year.
For the same period last year, the figures were only 2,559 cases and five deaths.
Expressing concern, Deputy Director-General of Health (Public Health) Datuk Dr Lokman Hakim Sulaiman said today: “Dengue is not only a big issue in Malaysia but also globally, as countries worldwide are experiencing an increase in deaths and cases and this is very worrying.”
According to the World Health Organisation (WHO), dengue cases has grown dramatically around the world in recent decades. Over 2.5 billion people – more than 40% of the world’s population – are now at risk from dengue and WHO currently estimates that there may be 50 million to 100 million dengue infections worldwide every year.
Lokman said the ministry has intensified its efforts to contain the outbreak but added that the public also needs to play an important role by keeping their houses and surroundings clean and free of mosquito breeding grounds.
“We can only contain the outbreak with public cooperation, especially from people living in urban areas,” he said, adding that three states have shown high incidences of the disease – Negri Sembilan, Federal Territories of Kuala Lumpur and Putrajaya and Sarawak.
He said that in view of the situation, even Health Minister Datuk Seri Dr S. Subramaniam was going to the ground once every two weeks to check on the situation.
The ministry has identified 594 dengue hotspots in the country, with 115 in Selangor, Negri Sembilan, Kuala Lumpur and Putrajaya, Lokman said.
He urged members of the public suffering from high fever (40°C/ 104°F) accompanied by two of the following symptoms: severe headache, pain behind the eyes, muscle and joint pains, nausea, vomiting, swollen glands or rashes, to seek immediate medical help.
“Do not wait till the situation worsens as severe dengue is a potentially deadly complication,” he said, adding that all hospitals and clinics were on the alert for dengue cases.
Extension of govt health clinics hours soon
PUTRAJAYA: Plans are afoot to extend the operating hours of government health clinics to accommodate the rising number of dengue patients, said Health Minister Datuk Seri Dr S. Subramaniam.
The move followed a 251% increase in dengue cases recorded in the first four weeks of this month, when 7,370 cases were reported against 2,098 in the same period last year.
A total of 2,229 cases were recorded throughout last week alone, marking a new weekly record high for dengue cases in the country’s history, he added.
“The number of patients in hospitals has increased significantly, especially at the emergency departments, where there is a need to reduce the load.
“There are already some health clinics that are open until 10pm, but we will study the possibility of extending their operating hours, especially at high-density areas in Selangor and Kuala Lumpur, where the load is heavy at the hospitals.
“Not all dengue cases require patients to be warded as some can be monitored without being warded depending on the doctor’s instructions,” he said at the ministry here yesterday.
He said a recent study conducted by the ministry found that the reproduction rate of the Aedes mosquitoes remained high in Penang (3.8%), followed by Sarawak (3.7%), Perlis (2.6%), Malacca (2.2%), Negri Sembilan (2.1%), Selangor (1.7%), Sabah (1.6%), and Kuala Lumpur and Putrajaya (1.5%).
Dr Subramaniam called on owners of premises that ensure that their places are free of Aedes mosquitos.
On dengue, what is the Health Ministry’s action plan? – Malaysian Doctor
FEBRUARY 07, 2014
Since early this year we have been hearing a lot of statistical data on the rise of dengue cases especially in Kuala Lumpur and Selangor.
The number of deaths is rising and number of aedes index statistics is also rising.
Dengue is a disease spread by a known vector the aedes mosquito. Control of the vector is an integral approach in managing the disease.
The Ministry of Health (MoH) has been very reactive in their approach of the problem so far by having many mortality review meetings and now extending clinic hours of its Klinik Kesihatan.
In other words more work for their clinical arm i.e. doctors that are seeing patients. The same doctors that are already overworked with increased number of patients are now expected to work longer hours to see more patients.
What we have yet to hear from MoH is what is their Public Health approach in preventing the continuing rise of the disease? The whole Public Health campaign against dengue has clearly failed with the rise in cases.
We wonder how much has been spent on the dengue awareness campaign last year by the District Health Officers in Selangor and Kuala Lumpur. We also wonder why when there are deaths in dengue only clinicians are questioned on their duties and not the District Health Offices.
When crime rates are high we question what is the police doing about it? Similarly when preventable disease rate is high we should be questioning what is the public health officers doing about it?
So is there someone in MoH that can provide holistic solution rather than spewing out statistical data only? – February 7, 2014.
* Malaysian Doctor reads The Malaysian Insider.
* This is the personal opinion of the writer or publication and does not necessarily represent the views of The Malaysian Insider.
Pagalavan's Avatar 
Many years ago when i attended dengue meeting at state level, we were informed by stupid political master who chaired the meeting that mass advert will ‘scare’ tourist coming to Malaysia, with Visit Malaysia 2014, So, don’t expect mass advert in mass media..
Impose heavy fines, at least RM500 for first offence, RM1500 for second and RM3000 + jail for third offence on those caught breeding aedes mosquitoes on their premises. Do it without mercy, fear or favour.
The move to extend the hours in KK has been made to alleviate the situation in ED which would be until 10/11pm, inclusive of weekends and public holidays. We are providing alternatives for the time-being as hospital ED’s are being overtly congested, and we could at least divert them to other KK’s if needed. But then again, the public education on not to abuse ED is the hardest to deal with, more than any chronic disease.
Here’s how the system works in the public health department with a new lab-confirmed registration of dengue cases:
1) Notification done within 24 hours
2) Lab test IgM/IgG and NS1 traced if available or patient asked to go to selected KK to perform Dengue combo rapid test within 72 hours (not many turn up for the test, so healthcare facilities are advised to perform a screening test instead if possible)
3) All lab confirmed cases would be entered into dengue registry within 72 hours (Previously relying on WHO 1997 dengue definition to register cases by epidemiologist within 24 hours from notification)
4) Control and prevention done in areas of confirmed dengue cases (Difficult in urban settings where source of infection could be almost anywhere from workplace, recreational area, eateries within 2 weeks prior to onset, hence utilizing home address) – This includes inspection for Aedes breeding spots and fogging if required (Fogging is no longer recommended as adults mmosquitoes survived maximum 3 weeks while the eggs can last up to 6-9 months)
Control activities are usually done within 3 days from notification unless the case has not been registered as dengue cases. With every suspected case being notified, each case has to be investigated. With a staffing capability of less than 20 health officer in a district health office to be in charge of liasing with community leaders, control activities and case investigations, the hundreds of cases a day(by usually 3-4 officers) are technically impossible to go down and visit each patient for investigations.
For a start,the public health team involves entomologists in their vector-control, instead of doctors alone to decide on the strategy, as you know, doctors are more knowledgeable in human anatomy only, after all. The vector-borne control disease unit is a multidisciplinary team consisting of public health specialists, entomologists, health investigation officers, as well as our field “troops” who does the groundwork risk assessment, inspection and fogging when required.
Not only that, there is also liasion with other units, which includes the law and inspectorate unit, health educational unit, as well as local councils in tackling the root of the problem, cleanliness, awareness and even structural flaws which may contain water suitable to breed mosquitors, such as Astro satelite dish. Community leaders and joint management board are called upon to raise awareness and remind the community to play their roles in preventing Aedes breeding.
The half-cut mineral water bottle is a form of ovitrap, used usually as a surveillance tool for presence and density of Aedes mosquitoes. The eggs if laid in the ovitrap will be collected and studied for its species identification. It is not something new, but has been used by entomologists even since 1960’s. The ovitraps are still being employed in outbreak and hotspot areas, and they are deployed in batches in the 200-400 meter radius area scattered in the homes for maximum efficacy. However, this would require manpower to inspect the ovitraps at least once a week, as the most common issue with ovitraps are when neglected, they become Aedes breeding spot themselves. Fogging can be done the closest 5 days apart, but it will only kill the adult mosquitoes before a new batch hatches after 5 days. While the adults can live up to maximum 3 weeks, the eggs can live without water for even 6-9 months. Source reduction is therefore preferred, as fogging would be required to be done continoulsy 5 days apart for 9 months to ensure no more adult mosquitoes from the eggs!
As for the fogging insecticides, there are various chemicals used and even on rotational basis to prevent resistance. However, just like any antibiotics, if the source remains, even the use of multiple agents will lead to eventual resistance, hence again the emphasis on the need for source reduction, which is the destruction of Aedes breeding sites.
Colloboration are being done with IMR for new research for Aedes prevention which includes autocidal ovitraps, space-spraying temephos to kill even adult mosquitoes, and even space-spraying BTI. Bioengineered mosquitoes are too costly as each mosquito cost at least RM100 and a large batch needed for a small area which is unproven for high rise area. Dengue virus detection in Aedes mosquitoes are even being researched by IMR as not all Aedes mosquitoes carry the virus, but a 10% transovarian trasmission by Aedes mosquitoes maintain the endemicity of dengue virus.Serotype surveillance are done by IMR, MKAK, MKAKK etc to detect the predominance of serotypes, as currently it has been shown that DenV-2 predominates (known to cause more severe secondary infection). Genotyping of each serotypes are also being done (Each serotype has various genotype and it has been revealed that the dengue virus variant in Johor and Singapore had different serotype and genotype, surprisingly)
Given the rise in dengue mortality, it is high time that we remind the public of the danger of dengue is not just of a minor flu. Dengue mortality meeting are held almost on weekly to biweekly basis, and scrutinizing both the public health team and clinicians as well. The public health team are scrutinized for the rising number of dengue cases in the area which could lead to the demise of the patient as part of the statistics, whilst the physicians are scrutinized to ensure that no mismanagement has been made, and should it happen, be corrected and improved to prevent future deaths.
Health education has also been intensified on all media including Facebook. For those living in KL and Putrajaya, perhaps the following site would be of interest to share the information to fellow friends to keep them aware of the dengue issue.
https://www.facebook.com/vektorkl
The move to extend the hours in KK has been made to alleviate the situation in ED which would be until 10/11pm, inclusive of weekends and public holidays. We are providing alternatives for the time-being as hospital ED’s are being overtly congested, and we could at least divert them to other KK’s if needed. But then again, the public education on not to abuse ED is the hardest to deal with, more than any chronic disease.
Here’s how the system works in the public health department with a new lab-confirmed registration of dengue cases:
1) Notification done within 24 hours
2) Lab test IgM/IgG and NS1 traced if available or patient asked to go to selected KK to perform Dengue combo rapid test within 72 hours (not many turn up for the test, so healthcare facilities are advised to perform a screening test instead if possible)
3) All lab confirmed cases would be entered into dengue registry within 72 hours (Previously relying on WHO 1997 dengue definition to register cases by epidemiologist within 24 hours from notification)
4) Control and prevention done in areas of confirmed dengue cases (Difficult in urban settings where source of infection could be almost anywhere from workplace, recreational area, eateries within 2 weeks prior to onset, hence utilizing home address) – This includes inspection for Aedes breeding spots and fogging if required (Fogging is no longer recommended as adults mosquitoes survived maximum 3 weeks while the eggs can last up to 6-9 months)
Control activities are usually done within 3 days from notification unless the case has not been registered as dengue cases. With every suspected case being notified, each case has to be investigated. With a staffing capability of less than 20 health officer in a district health office to be in charge of liasing with community leaders, control activities and case investigations, the hundreds of cases a day(by usually 3-4 officers) are technically impossible to go down and visit each patient for investigations.
For a start,the public health team involves entomologists in their vector-control, instead of doctors alone to decide on the strategy, as you know, doctors are more knowledgeable in human anatomy only, after all. The vector-borne control disease unit is a multidisciplinary team consisting of public health specialists, entomologists, health investigation officers, as well as our field “troops” who does the groundwork risk assessment, inspection and fogging when required.
Not only that, there is also liasion with other units, which includes the law and inspectorate unit, health educational unit, as well as local councils in tackling the root of the problem, cleanliness, awareness and even structural flaws which may contain water suitable to breed mosquitoes, such as Astro satelite dish. Community leaders and joint management board are called upon to raise awareness and remind the community to play their roles in preventing Aedes breeding.
The half-cut mineral water bottle is a form of ovitrap, used usually as a surveillance tool for presence and density of Aedes mosquitoes. The eggs if laid in the ovitrap will be collected and studied for its species identification. It is not something new, but has been used by entomologists even since 1960’s. The ovitraps are still being employed in outbreak and hotspot areas, and they are deployed in batches in the 200-400 meter radius area scattered in the homes for maximum efficacy. However, this would require manpower to inspect the ovitraps at least once a week, as the most common issue with ovitraps are when neglected, they become Aedes breeding spot themselves. Fogging can be done the closest 5 days apart, but it will only kill the adult mosquitoes before a new batch hatches after 5 days. While the adults can live up to maximum 3 weeks, the eggs can live without water for even 6-9 months. Source reduction is therefore preferred, as fogging would be required to be done continously 5 days apart for 9 months to ensure no more adult mosquitoes from the eggs!
As for the fogging insecticides, there are various chemicals used and even on rotational basis to prevent resistance. However, just like any antibiotics, if the source remains, even the use of multiple agents will lead to eventual resistance, hence again the emphasis on the need for source reduction, which is the destruction of Aedes breeding sites.
Colloboration are being done with IMR for new research for Aedes prevention which includes autocidal ovitraps, space-spraying temephos to kill even adult mosquitoes, and even space-spraying BTI. Bioengineered mosquitoes are too costly as each mosquito cost at least RM100 and a large batch needed for a small area which is unproven for high rise area. Dengue virus detection in Aedes mosquitoes are even being researched by IMR as not all Aedes mosquitoes carry the virus, but a 10% transovarian transmission by Aedes mosquitoes maintain the endemicity of dengue virus.Serotype surveillance are done by IMR, MKAK, MKAKK etc to detect the predominance of serotypes, as currently it has been shown that DenV-2 predominates (known to cause more severe secondary infection). Genotyping of each serotypes are also being done (Each serotype has various genotype and it has been revealed that the dengue virus variant in Johor and Singapore had different serotype and genotype, surprisingly)
Given the rise in dengue mortality, it is high time that we remind the public of the danger of dengue is not just of a minor flu. Dengue mortality meeting are held almost on weekly to biweekly basis, and scrutinizing both the public health team and clinicians as well. The public health team are scrutinized for the rising number of dengue cases in the area which could lead to the demise of the patient as part of the statistics, whilst the physicians are scrutinized to ensure that no mismanagement has been made, and should it happen, be corrected and improved to prevent future deaths.
Health education has also been intensified on all media including Facebook. For those living in KL and Putrajaya, perhaps the following site would be of interest to share the information to fellow friends to keep them aware of the dengue issue.
As for your No 4 , it does not happen. Since in Private hospitals we can get the NS1/IgM/IgG results within 30 min, diagnosis are made on the spot. Despite many notifications, no inspection or even fogging is done within 3 days!! Some patients even call the jabatan themselves and despite that, no one came. It even happened to my sister(her daughter got dengue) in Seremban. No one even came and 4 weeks later, both her husband and mother-in-law got Dengue.
I think depend on case by case. For my mother and brother-in-law cases, fogging done on the 2nd day of admission. From JB, Johor
Likely the fogging was done due to cases that occured before your mother and brother-in-law was admitted.
Currently there are colloboration with NGO’s to mobilize more force to help out in the current dengue situation, such as MIMPA, MRA, MUSTI, IMAM, GEMA and IKRAM. Hopefull it will involve more community NGO in the future and. Of course, it is best if the community itself could be empowered to perform self home-inspection.
Dr Paga, is it TRUE that all infectious diseases like dengue is only managed by government hospitals? For example any cases of dengue seen in private hospitals must be referred to government hospitals?
Nope. However we were advised to transfer any bad cases to GH.
@GP: Not necessary. Although there is a directive in Melaka to transfer all severe dengue cases to Malacca GH, hence all the dengue deaths in Malacca were in Malacca. Some states are trying to follow suite.
This is following some dengue deaths as a result of few factors including:
1) Inexperienced doctors: Some private physicians are inexperienced to manage severe dengue patients (Overseas physicians who came back attaching to tertiary subspecialty for 3 years before going out to private practice, not trained at all as HO or MO in Malaysia). There was a few who did nothing until patient’s hematocrit gradually raised from 40 to 60+ thorughout the admission of 4-5 days and knew nothing of dengue critical phase.
2) Infrequent reviews: Some physicians reviewed once daily even for severe dengue in ICU in private hospitals
3) No intensivist in ICU. Some ICU in private hospitals has no in-house intensivists, couple with OD review, makes it less ideal for managing ICU patients.
4) Inadequate staff: Nursing to patient ratio are not even 1-to-1 in certain ICU’s, and some nursing staff are not .even trained to manage medical emergencies in ICU. One or two even lacked a proper ICU vitals charting.
Generally not all hospitals are like that but in view of that few mistakes made, some states are getting jittery over it. However, other states like KL advocate for consultation instead, emphasizing on public-private collaboration. ICU beds are limited in public hospitals, GHKL included (although GHKL is not under state administration but directly answerable to KKM instead). Private practitioners are encouraged fellow colleagues who are more experienced in managing dengue in their hospitals or resort to consult ID physicians, ICU intensivists or Medical consultants in Public hospitals in co-management of patient to share the burden and allow the physicians to gain more experience to manage dengue patients. Even dengue CPG management is a guideline but clinical assessment and judgment are based on experience which can’t really be gained by mere reading.
Even specialists in public hospital are required to see all dengue cases (mild to severe) nowadays as public hospitals are not spared from the pitfall of management as well, usually due to overzealous fluid resuscitation at times when needed to make the call (Eg: 20+ years old patient with weight of 40+ kg and BP 90+/70+ but overall very good hydration status clinically (good pulse volume, CRT immediate, HR<80,etc) was pumped in with too much fluid boluses leading to cardiogenic shock and succumb to death later.
Yes. There are many overseas trained physicians who do not know how to manage Dengue cases. Every dengue patient is different and only an experienced physician will be able to pick up the warning signs which will tell you that the patient is going to deteriorate.
I wonder what happen to the pilot project that released 6000 genetically modified mosquitoes into the jungle in Pahang?
Any findings from the studies to combat with Dengue outbreak? What about our established Institute Medical Research, Institute of Public Health and all the Universities that emphasis on R&D….any consultation with these experts on the outbreak?
What is the output of million dollar/RM investment into the research?
The DG of MOH and YB besides reading out the statistics (compiled by the unsung heros of MOH, IKs) and urging public to do the same strategy-search and destroy?
Can he or YB offer something more creative?
—
~~~Taking the sting out of dengue~~~
Question: Based on these reports, public perception was, and still is, that the experiment was to use genetically-engineered Aedes aegypti male mosquitoes to stop the spread of dengue. If this was not the purpose, why was it not clarified by the Health Ministry from the start?
Answer: When the experiment was completed in January 2011, the results of the findings were published in the IMR website and was picked up by some media organisations.
Question: What is the next move after the Bentong trial? Is the ministry planning to carry out the suppression trial and, if so, when will it take place?
Answer: There are no immediate plans for a suppression trial. As this involves research and development, it is best to ask IMR. I cannot answer for them.
Question: Doesn’t IMR come under the jurisdiction of the ministry?
Answer: IMR answers to the director-general, not me. It is not under my jurisdiction.
Source: yourhealth.asiaone.com/content/taking-sting-out-dengue/page/0/2#sthash.ZHsSc142.dpuf
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