CYBER-INTERVIEW - PROF. LAM SAI KIT
Today's article will be an interview with Prof. Lam Sai Kit. Among the standard questions we ventured to get his opinion on the enterovirus 71 outbreak affecting Taiwan. I have been following the outbreak with interest and updates and further information can be obtained from my enterovirus outbreak site. (http://www.vadscorner.com/outbreak.html)
Prof. Lam Sai Kit is the Head of Department of Medical Microbiology and Senior Consultant Virologist, University hospital, Faculty of Medicine, University of Malaya.
He obtained his B.Sc in 1960 from the University of Western Australia, M.Sc two years later from University of Queensland and in 1966 his PhD from Australian National University. Among others he is a
Prof. Lam Sai Kit sits on the Editorial Board of several International journals as well as
Prof. Lam Sai Kit has published numerous papers and is interested in the following viruses - dengue, enterovirus (EV71), influenza, hantavirus and emerging viral infections.
4. You have been very active in the International scene particularly with WHO, and recently a Taiwan Newspaper quoted your presentation of four cases of enterovirus 71 which had helped the medical team in Taiwan make some clinical decisions in management. I have a few questions on this outbreak which now not only threatens Taiwan with more cases but also raises a possibility of spread of the disease to neighbouring countries of Hong Kong, China, Japan and Korea. Like the previous outbreak in Malaysia a lot of questions as to the exact aetiology of the disease is being questioned. How likely is it that this outbreak may spread beyond the borders of Taiwan?
The situation in Taiwan is very similar to that seen in Malaysia last year. When we had all those deaths in young children during an outbreak of hand, foot and mouth disease (HFMD), the nation was in a panic and there were actually parents who fled with their children overseas. I was contacted on the Internet by a paediatrician in Australia about some children who left Sarawak and had HFMD with positive EV71 isolation. I was able to reassure him that the risk was not high but the children should be closely monitored.
Japan too reported 3 fatal cases at about the same time as the Sarawak outbreak, with isolation of EV71 from one case. This is just to show that there is really no boundary in disease and what happens in one country is likely to spread to other countries. However, it must be remembered that EV71 is probably endemic in most if not all countries as a cause of HFMD but it may not give rise to severe infection.
5.From the lessons learned from the Malaysian episode how would you recommend the crises in Taiwan be managed.
Crisis management is dependent on the resources of each country and what applies to one may not be suitable for others. In Malaysia, it was a learning experience for us and we gained much from it. There is no substitute for good epidemiology as well as clinical and laboratory investigations and support. Teamwork is paramount in outbreak investigation and we in University of Malaya are grateful to the Ministry of Health to be invited to be part of the team. There have been criticisms levied on some officials in Taiwan and whether this is justified or not, I cannot comment. In an outbreak with many deaths involving young lives, the issue becomes very emotional and finger-pointing is not going to help. I hope the investigative team in Taiwan will stay calm and collected and be allowed to get on with the task ahead, which is outbreak control.
6.There have been a lot of questions recently on the Internet as to the exact pathogen involved. Some say its EV71 and some say its a type of Adenovirus, and yet some feel it may be a combination of pathogens. Based on your observation and experience taking into consideration clinical, serology, virology, post-mortem, previous literature (historical), etc what in your opinion is the likely pathogen.
I think good science and hard facts must apply in such a situation. We must be clear in the case definition based on clinical histories. Once we have a consensus on the cause of death, then we can move on and look at the laboratory evidence and see whether this can support the clinical events.
In the four cases in University Hospital, we were fortunate that permission for post mortem was given. Histopathology clearly showed brain stem encephalomyelitis, which can explain fully the clinical events of cardiorespiratory failure and pulmonary oedema. In addition, we isolated EV71 from these tissues. EV71 is not a new virus and it has been reported to cause similar outbreaks in Australia, Bulgaria, Hungary, Japan and now Taiwan.
As to other aetiological agents, we must follow the same process of deduction and clinical correlation.
7.Are there any rapid test to diagnose this disease and what and how much samples must be taken and to whom should it be sent?
The most rapid laboratory support is using autopsy materials. Our UH pathologists were able to provide provisional evidence of brain stem lesions within two days, using frozen sections. Virus isolation takes quite a few days but polymerase chain reaction for nucleic acid detection can be faster.
A number of laboratories were involved in the Malaysian outbreak and any of these labs should be able to provide assistance (IMR, Unimas, UM).
8.We have yet to see a final report from MOH or CDC on the outbreak in Malaysia. Important information from our experience should be made available as it would be useful to other countries and to us medical doctors as to diagnose a similar case or manage a similar outbreak. Care to comment?
The Minister of Health yesterday said that the 36 (now 38) deaths in Taiwan are the same as the 47 deaths in Sarawak and peninsular Malaysia last year. I guess this is equivalent to a final official report. Open communication is so vital and we should learn to share our information and experiences quickly. One up for the Internet!
9.Recently you have posted at Promed(http://www.promedmail.org/pls/askus/f?p=2400:1000) site that the EV71 found in Malaysia is a new strain. Care to elaborate?
We did not claim that the EV71 isolates are new strains. However, we did find characteristic 5'UTR sequences ( Link Changed) in the Malaysian isolates, which differ from published sequences. Whether these differences are significant or not, and whether they could account for the increased virulence, remain to be seen. From the press releases from Taiwan, there was also mention of hybrid or mutant viruses causing the outbreak there but we need to examine the evidence and compare with our findings.
10. Are you married? Any children? Are they on the Net?
Married for over 20 years to a tolerant wife who can put up with my long hours at work, and my travels. She has started using Microsoft words and feel quite at home on the net.
My 19-year-old son, Alex, is a computer-nut. He has a natural flare for it and before he left for Monash, he started a small company to provide service to his many clients. I don't think he made any money out of it because his clients were mainly his college mates who expected free service! It was a good learning experience.
My 15-year-old daughter, Sarah, gets on the net whenever she can. She finds it useful to source for information for school projects. She tries to compose musical pieces and finds that challenging. For relaxation, she plays games or watches VCD.
With that I let your "mouse" or your "keyboard" do the "talking".
Till next month, "Happy Surfing".
interviewed by Dr. Valerie Soo and Dr. Lee Hooi Ling
Emeritus Prof. Dato’ Dr. Lam Sai Kit is a renowned medical virologist whose outstanding research in infectious diseases has earned him many prestigious awards, including the Prince Mahidol Award for Public Health from Thailand, a Knighthood of the National Order of Merit by France and the prestigious Merdeka Award 2013 from Malaysia. Prof. Lam was a central figure in the discovery of Nipah virus in late 1990s, and was instrumental in developing in-house rapid diagnostic techniques to detect dengue virus. His work has resulted in more than 200 articles including those published in top peer-reviewed journals such as Nature, Science, Lancet and New England Journal of Medicine. After obtaining his PhD from the Australian National University, Prof. Lam joined Universiti Malaya (UM) in 1966 as a lecturer, and has remained in the same university ever since. At present, Prof. Lam serves as a Consultant for UM High Impact Research.
Q1. How did you get involved in the virology field?
My decision to work on virology is the turning point of my career. Prior to my PhD research, I was studying microbiology that focused mostly on bacteria. My sister is a bacteriologist, and she was trying to convince me to work on bacteriology. However, during that time, very little was known about viruses. I decided to do something different than everyone else, and work on something that is more difficult than the norm, so I took up virology.
Q2. You have worked in the World Health Organisation (WHO) as a scientist for two years, and remain very active in WHO. What was your role during your 2-year stint at WHO?
I was recruited by WHO owing to my work on Rapid Viral Diagnosis. Back in those days (1970s to 1980s), the way to diagnose viral infection was to isolate viruses from patients or to detect antibodies in response to viral infections in patients’ blood serum. Results from both of these methods were slow. Furthermore, many developing countries did not offer diagnostic service for viral infection because viral isolation using tissue-culturing techniques was very expensive.
My work on Rapid Viral Diagnosis was independent of viral isolation; instead the technique relies on the interaction between antigen-antibody to yield detectable fluorescence, and this technique gave diagnosis results on the same day. For instance, many children had lower respiratory infections. All we did was to take a swab from the back of the nose, and we immuno-stained the specimen against up to eight different viral or bacterial agents, and the presence of viral or bacterial antigens would yield fluorescence. Since this technique detects viral or bacterial antigens instead of than the patient’s antibodies, we did not have to spend weeks to grow up the virus, or wait for the antibody to appear in the blood serum. Normally by the time we could detect the antibody titer, the patient would have died or recovered from the infection.
Q3. What do you wish someone could have told you before you embarked on a career in virology?
I think the training background is very important, so I wish I had a medical degree. Instead of seeing the patients and assessing the symptoms directly, I had to depend on someone who had a medical training or a pathologist for clinical diagnosis. Having said that, I have no regret in working on medical virology.
The lack of awareness is not something we can change overnight, but we have to keep trying to educate the public
Despite that I never had a medical degree, I have had great colleagues and we worked as a team very well. For example, during the Nipah virus outbreak in 1997, I worked very closely with epidemiologists, clinicians, and neurologists.
Q4. What is your most memorable moment in your ~50 years of career?
The most memorable moment for me was when I was told by the CDC during the Nipah virus outbreak that we were handling a P4 agent. P4 agent is the most pathogenic agent in the world.
It was very a stressful and challenging situation in 1998. We faced huge pressure from the public and media, because the information we produced had impact on everyone in the country. In the initial stage, we did not know what was causing viral infections in swine farmers and how the disease spread, so we could not simply do things blindly (e.g. killing mosquitoes, assuming that it was another case of Japanese encephalitis that just hit the country in 1997). Working closely with the Ministry of Health, we tried to perform diagnostic tests as quickly as possible to exclude all known possible agents; however, all results were tested negative. After consulting with CDC, we finally identified a new virus (Nipah, that is) that was causing the outbreak.
There was a lot of unwanted attention, and people were passing unnecessary comments. Due to the death of many people, the public wanted “snap” answers. In a way, I understand their concern but the public did not understand that diagnosis results could not appear in a single day, especially in this case where the agent was unknown. We tried to stay focused on working in the lab, but there were also reporters snooping around trying to get answers. Along with the Ministry, we had to provide a lot of explanation to the media and public. We provided data to the Ministry, and let the Ministry disseminate the information. Both parties worked very well as a team.
Q5. Do you think Malaysian scientists are doing enough to create public awareness about their work or their field of science in general?
I think the public can be further educated in science. As a consultant for UM HIR, I made short write-ups of our research projects to be sent to the press in the hopes of capturing the public’s attention. In fact, UM HIR aims to produce a lot more write-ups to get the public interested in our research. We hope that by showcasing the work we are doing, the public and private bodies will realize the impact our research and start contributing to our research funds. The lack of awareness is not something we can change overnight, but we have to keep trying to educate the public.
Q6. Speaking of UM HIR, there have been a lot of collaboration going on between scientists funded by UM HIR and those from overseas. How were these collaborations initiated?
UM HIR is all about fundamental research, and we realized we have something unique to offer in every collaboration. For example, Prof. Barry Marshall (a Nobel Prize recipient in 2005) is interested in the phylogenies and origins of the gastric bacterium, Helicobacter pylori. We established the collaboration with him by offering the opportunity to examine the H. pylori strains in our country that were isolated from patients of various ethnic groups. Some patients show mild symptoms from H. pylori infection (e.g. developing gastric ulcer), and some eventually progressed to gastric cancer. Despite living under the same environment, what made these strains genetically different from one another? Are differences due to food, cultural, genes or a combination of all these factors? And of course, this collaboration would not have happened without the help of our country’s top gastroenterologists in providing these clinical samples.
Q7. In your opinion, what are the challenges of doing fundamental research in Malaysia?
First of all, research projects often takes years to mature. The main challenge we face is producing high-impact results within a short time. We want to be innovative, but too much bureaucracy that takes up unnecessary time is hampering our effort in developing fundamental research. For example, purchasing one piece of equipment may require going through multiple layers of approval.
too much bureaucracy that takes up unnecessary time is hampering our effort in developing fundamental research
Our country also puts heavy emphasis on targeted research that gears towards developing product. While this strategy works well for industries, it defeats the purpose of a university where fundamental research should take place. Therefore, the establishment of UM HIR is a great initiative for boosting fundamental research in Malaysia. We hope the government will continue to support HIR, as we believe this is one way to attract our talents back home and to retain our local talents.
Q8. Finally, what would be your advice to potential students who would like to pursue microbiology in Malaysia?
I would advise students to pick and choose their specialization. Start looking at job opportunities, whether in universities, healthcare systems, or in industries. For those who are interested to work on fundamental research, I would encourage them to start obtaining funding early in their career; otherwise, the path to doing basic research can be very frustrating. Gather information on the work they would like to focus on in a way that their work will have maximum impact to the society.