Church camp 2014
From 10-14 June 2014, my church held our retreat at Awana hotel at Genting highlands Malaysia. It was the same place we had last year. It was a 4 day 3 night camp. There were about 260 participants with ages ranging from young kids to the elderly. I was the only medical doctor and I was assisted by a nurse who was now a homemaker. This was a busy trip for both of us because we had to handle a food poisoning outbreak. I have documented the events in this article.
Content
Preparation
Food poisoning narrative
What is an food poisoning outbreak?
Effectiveness of advice and treatment
Notifying authorities
Bringing medicine through Malaysian customs
Medical insurance
Preparation
Pre trip preparations were similar to my 2013 camp. . See Preparing for a church camp
From 10-14 June 2014, my church held our retreat at Awana hotel at Genting highlands Malaysia. It was the same place we had last year. It was a 4 day 3 night camp. There were about 260 participants with ages ranging from young kids to the elderly. I was the only medical doctor and I was assisted by a nurse who was now a homemaker. This was a busy trip for both of us because we had to handle a food poisoning outbreak. I have documented the events in this article.
Content
Preparation
Food poisoning narrative
What is an food poisoning outbreak?
Effectiveness of advice and treatment
Notifying authorities
Bringing medicine through Malaysian customs
Medical insurance
Preparation
Pre trip preparations were similar to my 2013 camp. . See Preparing for a church camp
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I have updated the list of medical equipment and medications. You can download it here.
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Awana was a one hour drive from the Malaysian capital, Kuala Lumpur. Emergency evacuation for the critically ill meant driving to Kuala Lumpur. My Malaysian medical colleagues recommended Gleneagles Intan Medical Centre and University Malaya Medical Centre as the choice 24 hour accident and emergency center in Kuala Lumpur There was a Watson pharmacy at Genting Resort which was a 15mins drive up the mountains.
Food poisoning outbreak chronological narrative
2nd and 3rd day of camp
Awana resort was isolated. So all meals (breakfast, lunch & dinner ) were catered by the resort kitchen. It would be difficult to bring in food from another place. The food were prepared buffet style and were also consumed by other residents of the resort
The first patient with food poisoning presented on the 2nd night. She was an elderly lady who developed nausea and diarrhea that day. She was clinically stable. I advised her to rest and take fluids followed by small feeds when she felt better. I also prescribed loperamide. On the 3rd day morning 4 unrelated individuals ( 1 teenager and 4 middle aged ) had a combination of abdominal cramps, diarrhea and nausea. All were clinically stable. I retook their history and found out they all had eaten raw oysters last evening. I informed the retreat IC (in-charge) that we had a food poisoning outbreak situation. Together we approached the resort food & beverage supervisor and the head chef. The supervisor assured us that all cooked food was temperature tested. Nevertheless we requested them to increase the range of cooked food and serve uncut fruits. They had to continue serving uncooked food eg salads, desserts and roti prata because it was buffet style setting and the common kitchen was also serving other resort guests. During a gathering that morning, the retreat IC and I made a joint announcement regarding the food poisoning. I advised the campers to
· Avoid uncooked food and cut fruits.
· Not to overeat (cause all meals were in a buffet style)
· Those who are ill were to not to share their drinks and food; and to stay well hydrated
· Reminded everyone of my room number and contact.
4th day
There were 7 people (1 young man, 5 middle age and 1 elderly) having gastrointestinal symptoms. 2 of them had fever. An elderly lady felt weak so I did a room call. She had other co-morbities like diabetes and ischemic heart disease. Fortunately her vital parameters were stable and there were no signs of an acute abdomen. I also reviewed my 1st food poisoning patient. She had made a full recovery. By the 4th day my supply of medications had run out and I drove up to Watson pharmacy at Genting Highland to purchase more over the counter medications
5th day
This was the last day. The trip back to Singapore would take about 5 to 7 hours depending on traffic conditions and rest stops. Most were taking coaches and some were driving.
That morning, I made a final health advisory announcement. My advice was
· Anyone who felt unwell could approach me for prophylactic medications.
· All who had gastrointestinal symptoms were advised to have a very light breakfast and to bring along a plastic bag for vomiting. Travelling might aggravate nausea and vomiting.
· All drivers had to avoid the loperamide and prochlorperazine as these caused drowsiness. Drivers would have to stop more frequently to relief themselves
There were at least 20 people (teenagers to middle ages) who came to get prophylactic medications. I then realized that there were more victims who choose not to seek medical attention.
Aftermath
Fortunately the disease was self-limiting. I did not have to activate my emergency evacuation plan. I had reports that more people developed mild symptoms on the last day but recovered within the next few days. I noticed that no children were affected by the food poisoning. I think it is because children never ate raw osyters.
Learning points
This discussion is a self-appraisal and reflection on my actions and decision making during the food poisoning outbreak.
What is an food poisoning outbreak?
CDC defines a food poisoning outbreak as follows
"Two different people (not related) who attended the same function or ate at the same premises and who experienced similar symptoms as a possible outbreak"
The food borne pathogens can be bacteria, virus, parasites or toxins.
Effectiveness of my advice and treatment
My basic advice to stay adequately hydrated was correct. Most gastroenteritis treatments are symptomatic. . I dispensed a combination of paracetamol, antacids, loperamide and prochlorperazine. Routine use of antibiotics was not recommended as the illness is self-limiting.
I should have advised those suffering to avoid milk products because lactase deficiency can worsen the diarrhea. Gastroenteritis can also reduce concentration of enzyme lactase, impairing the small bowel to digest milk.
Food poisoning can be caused by toxins released from bacteria eg Bacillus cereus, E coli. These toxins are heat resistant and cannot be destroyed by reheating. If this was the cause of the disease then my advice to avoid cook food would be futile.
Notifying authorities
Food poisoning is a mandatory notifiable disease in Malaysia. That’s according to the Malaysian Infectious Disease Prevention and Control Act. Notification can be done by phone to the nearest district health office within 24 hours of diagnosis, followed by submitting a notification form. Laboratory confirmation is not required. I only notified my retreat IC, and together we informed the hotel staff.
We did not inform the Malaysian health authorities because
· We did not know the Malaysian laws. The hotel staff did not tell us to inform any authorities
· The hotel staff was very accommodating. They made the additional food arrangements as we had requested.
· We did not know how the local health authorities react. They could have shut down the kitchen for investigations. That meant we had to conclude the retreat activities and return to Singapore. Since the symptoms were mild and self-limiting, the camp co-coordinators felt the measures taken were sufficient for 2 more days. They were of course heavily influenced by my recommendations.
Bringing medicine through Malaysian customs
Malaysia customs accepts all medications, prescribed and over the counter. If there is use of scheduled drugs ( drugs with high abuse potential) eg morphine, then a letter from the prescribing doctor is necessary. All the medications must be carried in bottles or packets in which they were dispensed, and labeled with the patient’s name and description of the contents. Malaysian customs discourages carrying loose tablets into the country. Drug trafficking is punishable by death.
I had complied with the Malaysian customs recommendations. All my medications are bought using me and my family’s names and were packed properly.
Medical insurance and medico legal considerations
Until this incident I had not considered the medico legal implications. I am covered by Medical Protection Society MPS. Later I found out from MPS that at least a week before the trip, I had to notify them of my travel location, target population (Singaporeans or foreigners ), type of doctoring services and if the service was pro bono or paid. According to MPS, providing free medical coverage in an ASEAN country would not require top up of my insurance.
I made simple records of my consult on my smartphone note-taking app. I recorded patients name and a summary of the symptoms and treatment. I used note taking primarily as a reference if I had to review a patient again. If there was a medico-legal issue, I think these records would be considered deficient.
Things I could have done better
1. I had to inform MPS at least 1 week before my trip
2. I should have paid the resort for internet connections then I could do some research online. This would allow me to fill my knowledge gap.
3. Though common things happened commonly, I was glad to have planned for emergencies. I was able to top up my supply of medication at the local pharmacy.
4. I have to be more meticulous in my medical records
5. I should have asked everyone with gastrointestinal symptoms to report to me even if they wanted only conservative management. This would allow me to track the progression of the outbreak.
Reference
1. Ministry of Health (Malaysia), Surveillance for Infectious Disease, Disease Control Division. 2nd edition 2006. Case Definitions for Infectious Disease in Malaysia
2. Sharifa Ezat, Netty D, Sangaran G Paper review of factors, Surveillance, and burden of Food bourne disease outbreak in Malaysia Malaysian Journal of Public Health Medicine 2013 Vol 13 (2) :98-105
3. High Commission of Malaysia, Personal Prescriptions http://www.malaysia.org.au/travel3.html
Article 1st published on 14 Nov 2014
by Benjamin Cheah