By Lara Pickford-Gordon Thursday, August 21 2008

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Chief Medical Officer Dr Anton Cumberbatch....

Eight-year-old Sasha Bickram’s death will not be classified as caused by dengue fever since confirmatory testing and a postmortem were not done.

Health Minister Jerry Narace has evoked a barrage of criticism since he said Bickram’s death was not due to dengue. He was not fielding any questions yesterday and it was his Chief Medical Officer (CMO) Dr Anton Cumberbatch, advisor Dr Rohit Doon and legal advisor Barbie Roopchand who held a media briefing at the Health Ministry, Park Plaza, Port-of-Spain “to clarify matters” in Bickram’s death.

Dr Cumberbatch extended condolences to the Bickram family but said, “A confirmed established cause of death can only be certified by a post-mortem performed by a qualified pathologist and in this case blood investigation and the report from that investigation must also be supporting the pathologist’s report with respect to dengue.”

He said the ministry had an established procedure before a case is confirmed as dengue, that is, a post- mortem must be done as well as a confirmatory test for virus isolation at the Trinidad Public Health Laboratory. More sophisticated confirmatory tests are also done at the Caribbean Epidemiology Centre (CAREC).

He said the death certificate given by the head of paediatrics, San Fernando General Hospital, Dr Rajindra Parag was based on his clinical judgement and evidence at the time of Bickram’s death. He said “for the records” the cause of death (acute bleeding, dengue, sickle thalassaemia) listed on death certificate will remain.

Cumberbatch said although Bickram’s screening test was positive for dengue, the screening test alone was not conclusive.

“This screening test which is routinely being used by many health professionals and practitioners it is not diagnostic for dengue and its complications.”

Citing a preliminary report provided by the South West Regional Health Authority (SWRHA), signed by the medical director Dr Stephen Ramroop and chairman Dr Imtiaz Ahamad, Cumberbatch said sickle cell thalassemia was a “contributing factor to the cause of death”.

He said dengue was strongly suspected and was supported by a positive antibody test known as IgM. Bickram received appropriate supportive management during her stay. “The treatment of dengue is supportive until clinical parameters indicate dengue shock syndrome or dengue haemorrhagic fever.”

The SWRHA report said Bickram’s parents were informed of her clinical management at all times and senior physicians were involved.

“Blood samples were not submitted to the Public Health laboratory for confirmation, an autopsy was not performed.”

Bickram’s parents had requested a death certificate and one was issued.

“I understand that the consultant believed that his process in issuing the death certificate was humane and acceptable as many death certificates are issued at the hospital without post-mortems being done.”

But Cumberbatch said where infectious disease cases are suspected, “especially where there are other factors of complications as in Bickram’s case, it is necessary to establish the confirmed cause of death.”

He said this was also required for data purposes for this country to meet its national and international reporting obligations.

“When we say someone has died from dengue we must have that incontrovertible evidence.”

Cumberbatch said a positive or negative result from a screening test should only be used to assist doctors with the clinical management of patients. Cumberbatch said the screening tests being used could take five to seven days to be positive. “It’s really an antibody test and indicates whether you have been exposed to the dengue virus.”

He said some people can have dengue and within five to seven days show complications or die while their screening test remained negative while another person can show positive for up to six months. He said while an antibody test can show positive, a patient had to show a rise in antibodies before any determination could be made.

Asked if the doctor made an error in issuing the death certificate without an autopsy confirming the cause of death, Cumberbatch said, “It may have been the humane thing to do because the child was hospitalised for a number of days and if, in fact, he felt the parents may not have necessarily wanted to continue with this issue and requested the certificate.”

Asked about other deaths from dengue, he said at present there are no confirmed deaths but investigations are being done in “one or two suspicious deaths” to get confirmation.

Cumberbatch did not have updated figures regarding the number of cases of dengue but said he would provide an update to the media. The last official figure provided by the ministry was 120 dengue reports up to week 28.

He said surveillance reporting had been increased at health institutions from weekly to a daily basis as more people were visiting health facilities based on their clinical symptoms.

The ministry has re-issued clinical protocols for the management of dengue to clinical staff and staff at accident and emergency departments. Public education has also been intensified.

Cumberbatch said in early June the Health Ministry advised that 2008 was expected to see a rise in viral activity and dengue. He said dengue was a cyclical endemic problem and the last time the country had a problem was 2002. He said the ministry was working assiduously since the end of last year to put its house in order with respect to surveillance, management, clinical details to prevent a rise in viral activity.