Vague Rules Curb Covid-19 Testing In GP Clinics

Doctors’ groups want a practical guideline from MOH on how to conduct antigen rapid tests in private general practitioner clinics, instead of using Klinik Kesihatan settings.

KUALA LUMPUR, August 17 — Private general practitioners (GPs) complain that they’re still unable to test the general public for coronavirus amid ambiguous official guidelines, especially on quarantine, and infection prevention and control.

Physicians said they were left nonplussed by a July 24 virtual meeting with Ministry of Health (MOH) officials about guidelines for the private sector on using the antigen rapid test kit (RTK), saying MOH’s guidelines were based on the setting of public health clinics (Klinik Kesihatan), rather than GP clinics.

“The guidelines look more like a copy paste from CDC (United States Centres for Disease Control and Prevention) and WHO (World Health Organization), which are suitable for certain facilities only,” Malaysian Medical Association (MMA) honorary secretary general Dr R. Arasu said in his July 24 letter to Health director-general Dr Noor Hisham Abdullah, as sighted by CodeBlue.

Dr Arasu stressed that MOH officials should have visited GP clinics so they could better understand the infrastructure, patient flow, and when to conduct an antigen rapid test, and to subsequently prepare guidelines based on such observations.

“We were shocked when the officers at the discussion stated that ‘you can visit a Klinik Kesihatan to know better!’. It will be an uphill task if both the government and private sectors do not work as a team, instead choosing to treat the 7,000 MOH-trained general practitioners as their subordinates.”

Doctors raised questions on the infection prevention and control and quarantine criteria when GP clinics run antigen RTKs on low-risk people with influenza-like illnesses, such as whether GPs and their staff will be quarantined for 14 days if they diagnose a positive Covid-19 case.

MMA noted that a GP only makes the decision to test a low-risk person with flu-like conditions with the antigen RTK for coronavirus after the patient is registered, vital signs taken, and an examination conducted in the consultation room. GP clinics can also run antigen rapid tests for patients coming in specifically for such testing.

“What will happen to the doctor and staff if the patient is tested positive in both scenarios? Full personal protective equipment (PPE) is only worn when conducting the swabbing and testing,” Dr Arasu said.

Malaysian Medical Association (MMA) secretary-general Dr R. Arasu in Kuala Lumpur on February 21, 2020. Picture by Vinodh Pillai.

MMA complained about the lack of training on the testing process for Covid-19, even as training on swab-taking is ongoing. Private physicians are also confused about the interpretation of test results of antigen rapid tests, besides citing the lack of information on MOH’s Covid-19 website for private practitioners, compared to MOH staff.

The largest doctors’ group in Malaysia urged Dr Noor Hisham to get the relevant heads of department in MOH to have a session with GPs and to prepare a practical standard operating procedure (SOP) and guideline on conducting antigen RTKs in a GP clinic.

The antigen rapid tests are aimed as point-of-care testing for low-risk people so Malaysia can quickly track the Covid-19 epidemic, not to replace the diagnostic function of the gold-standard RT-PCR test. (MOH defines low-risk people as those who are not a person-under-investigation and those without a history of close contact with a positive Covid-19 case).

Dr Arasu pointed out that if 10 per cent of the 7,000 private GP clinics nationwide can do 10 tests a day, this would equate to 700 a day. Community-centric GP practices can run antigen rapid tests for patients with flu-like conditions, he said, thus reducing congestion in overcrowded government clinics and hospitals.

“MMA is of the opinion that GPs have been sidelined since the beginning of Covid-19 crisis — this is now an opportunity to work together in undertaking more tests and being able to help the MOH, more so with the impending waves of Covid-19 infection, sadly, we were wrong again.”

Malaysia has been reporting new unlinked Covid-19 clusters and cases, particularly in the northern region of Perlis, Kedah, and Penang, over the past several days, as the source of infection of these community transmissions is unknown. MOH, however, maintains that it does not need to expand Covid-19 testing beyond its targeted testing approach because of the extremely low positivity rate of below 1 per cent. Hence, MOH only runs 5,000 to 6,000 tests daily, despite a maximum capacity of 38,600 tests a day.

GPs Asked For Google Earth Pictures Of Clinics

Dr G. Shanmuganathan, honorary secretary of the Private Medical Practitioners’ Associations, Malaysia (FPMPAM).

Dr Shanmuganathan Ganeson, honorary secretary of the Private Medical Practitioners’ Associations, Malaysia (FPMPAM) — who had attended the July 24 MOH webinar — said doing an RT-PCR swab for coronavirus was “easy as ABC” for GPs. But what physicians want is training on ensuring control of contamination via set guidelines in the chain of sampling and delivery to the lab, with correct disposal of exposed waste and PPE.

He echoed MMA’s concerns that the Covid-19 health booth screening guidelines by MOH’s Private Medical Practice Control Section (CKAPS) were impractical in a Malaysian GP clinic setting.

“Instead of dropping in to advise GP applicants who wished to do mass screening, on how to improve the screening to comply with regulations, they kept asking for one thing or another via email, often taking more than two weeks to provide answers,” Dr Shanmuganathan told CodeBlue.

“I was asked to provide Google Earth pictures of my clinical setting! They actually have a detailed layout plan of my clinic done by an architect, which we need to be supplied to be registered.”

Dr Shanmuganathan pointed out that MOH needs to be practical with its guidelines by not imposing lab-centred guidelines on clinics, noting that a biosafety laminar flow cabinet — which is “rather encouraged” by MOH for use in antigen RTK testing — was too expensive to consider as part of testing expenditure.

“The GPs are probably better off without the unending ivory tower micro-guidelines. We can just take it off from WHO guidelines,” he said.

“After all, GPs are real entrepreneurs suffocated by multifold regulations enforced by salaried employees who don’t appreciate that their monthly earnings come from our taxes, nor appreciate the difficulties of existence in private practice.”

The FPMPAM official said private GPs had contributed to the Covid-19 battle “entirely on their own”, noting that while many GP clinics shut down at the start of the Movement Control Order (MCO) last March due to the lack of PPE, other physicians invented their own protective gear with DIY raincoats and goggles.

Dr Shanmuganathan also raised complaints by many GPs that laboratories had received the lion’s share of testing opportunities, claiming that by the time MOH gave approval to some GPs to screen people for Covid-19, not much testing was left to be done.

“In the GPs, they [MOH] have a highly experienced pool of doctors at every corner of the country, rural and urban, who can play a vital role in public health containment of the virus. With enough labs now, they can help in early detection via screening and provide better data for contact tracing, prevalence studies and health strategies.

“If a Covid-19 vaccine surfaces, who better than the GPs to institute vaccination in a cost efficient equitable manner?” Dr Shanmuganathan said.

Medical Practitioners Coalition Association of Malaysia (MPCAM) president Dr Raj Kumar Maharajah also gave his input by saying that GPs who are on the ground and closest to the community can conduct the antigen RTKs, which can give immediate results.

“Many low-risk patients are already requesting it and we are unable to conduct without a clear SOP,” Dr Raj Kumar told CodeBlue.

“SOP and guidelines should be based on GP clinics. The floor plans of each GP clinic is available in MOH. They just need to do the SOP since they have the experts.”

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