Medical Muddling in a Children's Epidemic

飞雪寒冰

Statistics describing the rapid spread of an ugly, blistering and sometimes deadly disease among children have been piling up at the offices of local, provincial and central government health bureaus for months.



The figures underscore the severity of this year’s epidemic of hand, foot and mouth disease (HFMD) in China: nearly 42,000 cases and 18 deaths were confirmed in 30 regions nationwide between January 1 and March 26. Most victims were under age five.



The statistics also fueled serious concerns about official responses to the outbreak in some areas. Case reports surged suddenly in some communities following allegations that local health officials had dragged their feet or even deliberately withheld statistics, in effect covering up a public health emergency.



In Beijing, the Ministry of Health’s information director Deng Haihua said March 27 that some local health offices may have failed to properly report HFMD cases.



Accurate reporting of HFMD is especially important because a stricken child stands the best chance of recovery if medical care is provided within two days of infection. Otherwise, in severe cases, death can occur in just three days.

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After a week in Minquan, the ministry team said the county since the beginning of the year had 419 HFMD cases and two deaths -- the highest disease level in Henan. The statistics stood in sharp contrast to the local health records which, for example, listed only 12 cases for the period March 7 to 24.



After lifting a veil that had masked the true extent of the epidemic, the central government health ministry dispatched a second team of experts to Minquan to work with local officials.



But the debate over HFMD statistics and the responses of local health officials is not over. So far, officials in neither Henan nor Minquan have released information about 10 of the deaths confirmed in the health ministry’s fatality report.



At a news conference March 27, the ministry’s Deng faulted Minquan officials for improper epidemic controls. Some doctors lacked standard training for diagnosing and treating HFMD, he said, and the process for confirming cases was too complicated.

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Minquan Probe



Citizens and the media got involved in the allegedly uneven health reporting procedure in Minquan as well.



China National Radio reported March 18 county officials had concealed an HFMD epidemic by forging medical records, and said at least two babies suspected of having HFMD had died. That same day, the health ministry sent a team of experts to investigate the Minquan situation.



Wasting little time, the ministry said March 19 it could not rule out the possibility that HFMD may have caused the Minquan deaths. The patients’ doctors had offered vague descriptions of the symptoms, although it was unlikely they tried to conceal the epidemic by forging medical records.



Ministry experts also noted that local health centers profited from the epidemic by promoting and selling certain health products to patients.



A few days later, Henan’s Bureau of Health announced that, based on the radio report and health ministry investigation, Minquan leaders and health officials had been punished.



China National Radio, however, was not finished. On March 24, the radio reported that the health ministry team confirmed the HFMD-related death of a baby named Hu Wenyan in Minquan, a fact that conflicted with the official Henan report that no deaths related to the outbreak had occurred.



The radio service also learned that at least 10 babies believed to be infected with HFMD had died in Minquan between January 25 and March 17. One death occurred in January, four in February and five in March, the report said.

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Confusion in Heze



In Heze, public concerns over official handling of HFMD reports have been brewing since mid-March. More than 20 local residents started using an Internet forum to post claims that local officials had concealed several deaths. Some claimed at least 20 had died.



Following these clues, a Beijing News investigation revealed that at least four babies suspected of having HFMD died in a Heze hospital between March 19 and 22, and that at least two babies whose HFMD was officially confirmed had died between March 8 and 23, according to one patient’s relative.



After the media reports appeared, three Ministry of Health officials traveled March 25 to investigate the epidemic in Heze. Also at that time, Shandong provincial health officials announced HFMD had killed two babies in Heze: Seven-month-old Liu Xinkun died March 22, and 15-month-old Zhang Heng died the next morning. Neither case had been reported to the media.



Late March 25, Heze health officials used the Shandong division of the state news agency Xinhua to report that HFMD had been blamed for the deaths of two of six babies in the city between March 8 and 23. At least three of the other four cases involved suspected HFMD infections, the report said.



Three deaths were reported by Heze-area media. The reports said health officials suspected HFMD in the March 8 death of Zhang Yike. The official cause of death for Cui Shuyue, however, was encephalitis. And it was unclear whether Cheng Mengjiao’s death had been counted as an HFMD fatality in Heze or the nearby city of Jining.

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HFMD diagnosis is even more complicated in Shandong’s Juancheng County, where rules adopted March 18 say a case only can be officially confirmed by a provincial medical institution. Even then, an infection may be counted as merely a “suspect” case unless a hospital official, local health bureau director, and between one and three professors sign off.



At Ditan Hospital in Beijing, China’s largest hospital for infectious disease, Deputy Director Cheng Jun told Caijing that, under central government guidelines, any doctor in an infectious disease or pediatrics department has the authority to confirm an HFMD case.



Once confirmed, Cheng said, a doctor is required to report a case within 24 hours. If a doctor fails to report, the medical facility involved in the case must file a report with local epidemic control officials.

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Clashing Standards



The revised figures from Heze, Minquan and other regions were included in the Ministry of Health report March 26, which said children under age five comprised 93.9 percent of the 41,846 HFMD cases detected nationwide since the beginning of the year. The nationwide caseload included 94 severe instances and 18 deaths as of that date.



HFMD is an infectious disease caused by a virus. Symptoms include painful sores on hands and feet as well as blisters in and around the mouth. Some young patients may suffer additional complications such as myocarditis, pulmonary edema or meningitis.



The disease has recurred annually in some parts of China with the arrival of spring. Last spring, for example, 6,049 cases and 22 deaths were reported in the city of Fuyang in Anhui Province.



The central government’s health ministry outlined specific guidelines for handling HFMD last May, after authorities categorized it as a serious, Class C infectious disease. The guidelines say that, in most cases, any qualified pediatrician can confirm that a patient has HFMD.



But in some areas, local officials have written their own rules. In Heze and Minquan, for example, officials say a case cannot be confirmed or publicized without medical reports from three doctors.



Local guidelines that conflict with Ministry of Health standards reduce options for independent medical judgment and, instead, can require reviews by several physicians and sometimes top health department officials before an HFMD can be officially confirmed

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Indeed, a special team of experts headed by Minister of Health Chen Zhu was recently dispatched to the Shandong Province city of Heze and Henan Province’s Minquan County to investigate local handling of the epidemic and supervise disease control.



“With limited work experience and skills, local governments may have failed to report some HFMD cases,” said Deng. “Local health administration offices will investigate whether the local governments and health departments intentionally concealed the cases, and will publicize results.”



The ministry team was formed in late March after several media reports said Heze health officials had failed to report or concealed at least three reports of HFMD-related deaths. They were also responding to reports by China National Radio that Minquan officials may have covered up HFMD cases and 10 deaths.



Heze’s health bureau later acknowledged the deaths of four babies whose names had been excluded earlier from local HFMD fatality reports. As of March 29, Heze had issued an updated report that listed 2,527 patients, 80 severe cases and five deaths.



Henan officials, including those who took heat for the alleged Minquan cover-up, also beefed up their records by reporting 4,761 HFMD cases including 37 severe instances and seven deaths as of March 26.