Date: Sat, 13 Jul 2019 10:41:55 +0200

Kuala Lumpur, July 13, 2019 (AFP) - Flash floods killed a Dutch tourist in a popular cave located in the rugged Mulu National Park on Malaysia's Borneo island, an official said Saturday, as a search continues for a missing guide.    Local fire and rescue chief Law Poh Kiong identified the dead man as 66-year-old Peter Hans Hovenkamp from Utrecht in the central Netherlands.     "He died due to drowning following flash floods in the caves. His body was found in a river inside the cave and was taken to the Miri public hospital for a post-mortem on Saturday," he told AFP.   Law said a search-and-rescue operation involving 16 officers had been launched to locate 20-year local tour guide Roviezal Robin.   Eight other tourists in the same group "almost become victims" but fled to higher ground and escaped from being washed into the river, Law added.

Hovenkamp was reported missing on Friday while the group was touring the popular "Deer Cave", home to an estimated three million bats which form amazing patterns in the sky when they leave each dusk.   Mulu park, located in the remote Borneo jungle of Sarawak state and famous for its caves, cliffs and gorges, is a UNESCO world heritage site.   It sees thousands of visitors annually, particularly for its cooling rains during the summer months.    Law described the death as "a freak tragedy."
Date: 23 Jun 2019
Source: Outbreak News [edited]
<http://outbreaknewstoday.com/methanol-poisoning-cluster-in-malaysia-89090/>

The Malaysia Ministry of Health is reporting a methanol poisoning cluster believed linked to counterfeit alcohol.

For the period of 11-21 Jun 2019, 3 methanol poisoning clusters were reported to the National Crisis Preparedness and Response Center (CPRC). The incidents involved 19 cases from the following states:
Penang (8), Johor (6) and Negeri Sembilan (5). The cause of the methanol poisoning was believed to be due to the counterfeit liquor branded by Myanmar Whiskey, Miludeer Beer, Whiskey 99 and Martens Extra Strong.

The cluster of methanol poisoning cases in Penang began on 11 Jun 2019 and involved 8 Myanmar citizens. Two of the cases have died. They had been drinking Myanmar branded whiskey. The drink was purchased from the same seller who sells directly at the premises where these poisoning victims work. On 21 Jun 2019, one methanol poisoning case was still being treated at a Penang hospital in critical condition, while 5 others were discharged.

In the state of Johor, reporting of methanol poisoning cases has been received since 18 Jun 2019. It involves 6 cases, 3 Malaysians and one Pakistani, Nepalese and Indian, respectively. Three of the cases involved were found to have consumed a drink believed to be counterfeit branded Miludeer Beer. Four of the cases of methanol poisoning have died. On 21 Jun 2019, one case was still being treated at the Sultanah Aminah Hospital (HSA) in critical condition, and one more reported case of blurred vision was being treated in a regular ward at Sultan Ismail Hospital, Johor Bahru, Johor.

The Negeri Sembilan Health Department (JKNNS) reported one methanol poisoning cluster on 20 Jun 2019 involving 5 cases from the Port Dickson district including 2 deaths. It involves 3 Malaysians, one Indian citizen and one Myanmar citizen. Investigations found cases involved drinking alcoholic beverages allegedly branded Miludeer Beer (2 cases), Whisky 99 (1 case) and Martens Extra Strong (1 case), while one case had no brand information. On 21 Jun 2019, 3 cases were being treated at Port Dickson Hospital, 2 critical cases, and one case in a regular ward.

Clinical samples were taken from all 19 cases for methanol test analysis. The results showed 5 positive cases of methanol and one negative case of methanol but showed symptoms and clinical signs of methanol poisoning. Laboratory results for the remaining 13 cases are still pending.

The Penang State Health Department, Negeri Sembilan and the State of Johor have collaborated with the Royal Malaysian Police and Royal Malaysian Customs in an investigation to identify the sources of the counterfeit alcoholic drink.

The MOH continues to monitor the situation and take preventative and control measures to address these methanol poisoning incidents. Consumers are advised to ensure each purchased alcohol product has a label containing complete manufacturer, importer, agent and listing information.

Consumers are also advised to avoid consuming home-brewed alcoholic beverages or alcohol being sold at low prices.

If individuals have symptoms of methanol intoxication such as stomach-ache, nausea, vomiting, headache, and vision loss within 5 days of consuming an alcoholic drink, MOH advises them to seek immediate treatment at any clinic or the closest hospital.
===========================
[Methanol toxicity initially lacks severe toxic manifestations. Its pathophysiology represents a classic example of lethal synthesis in which toxic metabolites cause fatality after a characteristic latent period. In other words, these people may not realize they are sick or ill until some time after consumption.

Methanol is sometimes used as an ethanol substitute for alcohol. Foods such as fresh fruits and vegetables, fruit juices, fermented beverages, and diet soft drinks containing aspartame are the primary sources of methanol in the human body, but [they contain] minute quantities.

Wood alcohol is also known as methanol. It is a commonly used toxic organic solvent causing metabolic acidosis, neurologic issues, and death when ingested. It is a part of many commercial industrial solvents and of adulterated alcoholic beverages or is mistaken as being the same as alcohol for ingestion. Methanol toxicity remains a common problem in many parts of the developing world, especially among members of lower socioeconomic classes.

Neurological complications are recognized more frequently due to advanced technologies and because of early recognition of the toxicity and advances in supportive care. Hemodialysis and better management of acid-base disturbances remain the most important therapeutic improvements.

Serum methanol levels of greater than 20 mg/dL correlate with ocular injury. Funduscopic changes are notable within only a few hours after methanol ingestion. The mechanism by which the methanol causes toxicity to the visual system is not well understood. Formic acid, the toxic metabolite of methanol, is regarded as being responsible for ocular toxicity, and blindness can occur in humans.

The prognosis in methanol poisoning correlates with the amount of methanol consumed and the subsequent degree of metabolic acidosis; more severe acidosis confers a poorer prognosis. Methanol has a relatively low toxicity. The adverse effects are thought to be from the accumulation of formic acid, a metabolite of methanol metabolism. The prognosis is further dependent on the amount of formic acid that has accumulated in the blood, with a direct correlation existing between the formic acid concentration and morbidity and mortality. Little long-term improvement can be expected in patients with neurologic complications.

The minimal lethal dose of methanol in adults is believed to be 1 mg/kg of body weight. The exact rates of morbidity and mortality from methanol intoxication are not available.

Rapid, early treatment is necessary for survival, but sequelae such as blindness may be permanent.

Metabolic acidosis in methanol poisoning may necessitate the administration of bicarbonate and assisted ventilation. Bicarbonate potentially may reverse visual deficits. In addition, bicarbonate may help to decrease the amount of active formic acid.

Antidote therapy, often using ethanol or fomepizole, is directed towards delaying methanol metabolism until the methanol is eliminated from the patient's system either naturally or via dialysis. Like methanol, ethanol is metabolized by ADH, but the enzyme's affinity for ethanol is 10-20 times higher than it is for methanol. Fomepizole is also metabolized by ADH; however, its use is limited because of high cost and lack of availability.

Hemodialysis can easily remove methanol and formic acid. Indications for this procedure include (1) greater than 30 mL [1 oz] of methanol ingested, (2) serum methanol level greater than 20 mg/dL, (3) observation of visual complications, and (4) no improvement in acidosis despite repeated sodium bicarbonate infusions.

Intravenous administration of ethanol in a 10 percent dextrose solution may be helpful. As ethanol prolongs the elimination half-life of methanol, the treatment may take several days, and the patient should be hospitalized. Dialysis may be necessary to prevent kidney failure as well. Hemodialysis remains an effective treatment.

Portions of this comment were extracted from:
<http://emedicine.medscape.com/article/1174890-overview>,
<http://emedicine.medscape.com/article/1174890-treatment>,
<https://www.nap.edu/read/4795/chapter/35>, and
<https://www.cdc.gov/niosh/ershdb/emergencyresponsecard_29750029.html>. - ProMED Mod.TG]

[HealthMap/ProMED map available at:
Malaysia: <http://healthmap.org/promed/p/147>]
Date: Tue 18 Jun 2019
Source: Eleven Media Group, The Star report [edited]
<https://elevenmyanmar.com/news/measles-outbreak-in-malaysia-is-a-wake-up-call-asianewsnetwork>

The common measles, combined with a fragile immune system and severe malnutrition, have been cited in the possible deaths of 15 Orang Asli of Kampung Kuala Koh in Gua Musang [Kelantan state], says the Health Ministry.

But health authorities are concerned that only a handful of the Orang Asli have received the measles-mumps-rubella (MMR) vaccination needed that would have strengthened them against the disease. Describing the deaths as a "wake-up call", Minister Datuk Seri Dr Dzulkefly Ahmad said only 61.5% of those in Kampung Kuala Koh have received their 1st dose of MMR vaccine, and only a mere 30% have received booster shots. "The main factor that has caused the spread of measles among the Orang Asli in Kampung Kuala Koh is the low coverage of MMR immunisation among them. "This, added with malnutrition, has contributed to the risk of infection and complications. "This is a real wake-up call. In our mission to provide universal health coverage and not to leave anyone behind, we need to ensure what happened in Kampung Kuala Koh does not recur," he told a press conference [in Putrajaya] yesterday [17 Jun 2019].

Dr Dzulkefly said the nomadic lifestyle of the Bateq tribe had made it even more challenging for the ministry's medical teams to reach out to them and provide the necessary health services. "During my visits to Orang Asli settlements in Cameron Highlands [Pahang state], we saw how the immunisation level there is at 100%. This needs to be our benchmark. "The ministry will take this on and work with other agencies, such as the Orang Asli Development Department to prevent a repeat of Kampung Kuala Koh," he said. Dr Dzulkefly said laboratory tests found that 37 out of 112 people examined tested positive for measles. "Lab tests for other diseases, such as tuberculosis, melioidosis, leptospirosis, and coronavirus have proven negative," he said.

There are reportedly 15 deaths due to the outbreak so far, with 3 classified dead due to pneumonia and multiple organ failure, due to complications from measles.  The most recent death was of toddler at the Raja Perempuan Zainab Hospital in Kota Baru on [Sun 16 Jun 2019]. The 2.5-year-old child was suffering from severe malnutrition and weighed 7kg [15.4 lb], which was unusually light for children of that age. "Because of severe malnutrition, the child's immunity became low, causing him to suffer from measles. "After being afflicted by measles, the child suffered from pneumonia complications and multi-organ failure," said Dr Dzulkefly.  He also said that the police and the ministry's forensic team had exhumed 12 bodies from graves at Kampung Kuala Koh. A post-mortem will be conducted on the remains at the Hospital Gua Musang to ascertain the causes of death.

Dr Dzulkefly said the ministry would ramp up its immunisation drive to all Orang Asli residing in affected areas and increase the Infection Prevention Control (IPC) at its health facilities. "Other states have also been asked to raise their measles infection surveillance. If there are deaths displaying similar symptoms, the state governments must alert the ministry immediately via the Crisis Preparedness and Response Centre," Dr Dzulkefly added.
========================
[According to ProMED-mail post Undiagnosed illness - Malaysia: fatalities, iron mining wastewater, TB susp, RFI http://promedmail.org/post/20190610.6511742, an outbreak in the Bateq indigenous community in northeastern Malaysia that affected all age groups started during the 1st week of May 2019. Many were said to have suffered from cough, fever, and breathing difficulties, but no mention was made of a skin rash.

The outbreak has now affected a total of 112 individuals; 15 have died. Postmortem reports of 2 patients suggest the cause of death was pneumonia. As mentioned in the article above, death in the latest patient was reported to have been complicated by secondary bacterial pneumonia and multiorgan failure (<https://www.nst.com.my/news/nation/2019/06/496885/batek-boy-dies-after-eight-days-hospital>). Recently, 37 out of the 112 are said to have tested positive for measles and the measles immunization rate in this community us said to be particularly low. Although tuberculosis (TB) had been suspected, the news report above says that tuberculosis, melioidosis, and leptospirosis have been ruled out.

Measles outbreaks can have high attack rates in unimmunized communities with many deaths, especially among young, malnourished children, particularly those with vitamin A deficiency. Measles symptoms typically include high fever, cough, runny nose, watery eyes, and rash that appears 3 to 5 days after the 1st symptoms. Serious complications include pneumonia and encephalitis. As many as 1 out of every 20 children with measles gets pneumonia due to the measles virus itself or bacterial superinfection, and is the most common cause of death from measles in young children (<https://www.cdc.gov/measles/symptoms/complications.html>).

In immunocompromised persons, diffuse progressive pneumonitis caused by the measles virus may occur in the absence of a rash, and is the most common cause of death in these patients (<https://academic.oup.com/jid/article/189/Supplement_1/S4/823958>).

How the diagnosis of the illness among the Bateq was confirmed to be measles is not stated in the news report above. However, serologic testing by enzyme-linked immunoassay (EIA) for IgM antibody is commonly used to confirm the diagnosis. The IgM antibody response is transient, being detectable for at least 30 days after rash onset. Tests that are negative in the 1st 72 hours after rash onset should be repeated.

The Bateq are part of the Orang Asli indigenous people of Peninsular Malaysia (<https://en.wikipedia.org/wiki/Batek_people>). Orang Asli constitute only 0.5% (about 150 000 people) of the total population of Malaysia; the majority of Orang Asli live in rural areas in poverty, with a high infant mortality rate (<https://en.wikipedia.org/wiki/Orang_Asli>). Gua Musang is a town, district and parliamentary constituency in southern Kelantan, Malaysia. Kelantan, located in the northeastern corner of the peninsula is a state of Malaysia on the border with Thailand to the north (<https://en.wikipedia.org/wiki/Kelantan>).

A map showing the location of Gua Musang can be found at
<https://goo.gl/maps/L9ACrtHSASaimCpQA>. - ProMED Mod.ML]

[HealthMap/ProMED-mail map of Malaysia
<http://healthmap.org/promed/p/11375>]
Malaysia - National. 7 Apr 2019

Malaysian health officials reported (computer trans.) more than 38,000 dengue fever cases through 6 Apr [2019]. Of this total, 59 fatalities have been reported. Nearly 6 out of 10 cases have been reported from Selangor state, followed by Kuala Lumpur and Johor. There are reports of the future release of Wolbachia-infected _Aedes_ mosquitoes to try to stem the spread of dengue. In all of 2018, 80 615 cases and 147 deaths were reported.
<http://outbreaknewstoday.com/malaysia-dengue-total-tops-38000-cases-71104/>
Date: Thu 14 Mar 2019, 12:50 PM
Source: The Indian Awaaz [edited]
<http://theindianawaaz.com/malaysia-100-schools-closed-after-hundreds-of-people-fall-ill/>

Over 100 schools have been closed after the dumping of toxic waste into a river caused hundreds of people to fall ill, including many children, authorities said in Malaysia. Over 500 people, many of them school pupils, have received medical treatment after inhaling the fumes.

A lorry [truck] is believed to have dumped the waste in southern Johor state last week, sending hazardous fumes across a wide area.

Education Minister Maszlee Malik said his Ministry has decided to close all 111 schools in the Pasir Gudang area immediately.
=========================
[It is very difficult to comment on what the toxin might have been. We know it produced fumes which were inhaled and resulted some individuals being treated, possibly for respiratory issues.

It is sad, and since it was dumped in a water way, we may see other individuals, and/or animals affected by the toxin. - ProMED Mod.TG

[HealthMap/ProMED map available at:
Johor, Malaysia: <http://healthmap.org/promed/p/14234>]
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