Rare disease in Malaysia: Challenges and solutions

Knowledge, attitudes, and practices of primary healthcare practitioners in low- and middle-income countries: a scoping review on genetics

Individualised treatment, including genetic services, calls for an increased role of primary healthcare practitioners (pHCPs) in diagnosing and caring for individuals with genetic conditions. PHCPs' genetics knowledge and practices must be current to ensure adequate care. A scoping review was conducted to explore peer-reviewed articles on the knowledge, attitudes, and practices (KAPs) of pHCPs concerning genetics, genetic testing, and genetic services. English-language human genetics/genomics articles published between January 1990 and April 2022 in low- and middle-income countries (LMICs) were included. Twenty-eight articles from 16 LMICs in five World Health Organisation (WHO)-defined regions met the inclusion criteria and showed a steady increase in publications, with varied contributions by region. The Eastern Mediterranean Region (EMR) contributed the most articles (n = 8), while the Western Pacific Region (WPR) had the least (n = 2). Brazil published the most articles (n = 6), while ten countries contributed one article each. Fifteen articles included knowledge, 19 included attitudes towards genetics, and eight included genetic practices. The findings indicate that pHCPs in LMICs lack knowledge of genetics and its applications despite their positive outlook towards genetic services. Barriers such as limited resources, financial constraints, and cultural or religious beliefs hinder access to genetic services. Enhancing pHCPs' genetics education is vital for improving care for those affected by genetic conditions. The scarcity of literature in LMICs emphasises the need for research on educational interventions to improve patient outcomes and family support.

Unveiling the genetic tapestry: Rare disease genomics of spinal muscular atrophy and phenylketonuria proteins

Rare diseases, defined by their low prevalence, present significant challenges, including delayed detection, expensive treatments, and limited research. This study delves into the genetic basis of two noteworthy rare diseases in Saudi Arabia: Phenylketonuria (PKU) and Spinal Muscular Atrophy (SMA). PKU, resulting from mutations in the phenylalanine hydroxylase (PAH) gene, exhibits geographical variability and impacts intellectual abilities. SMA, characterized by motor neuron loss, is linked to mutations in the survival of motor neuron 1 (SMN1) gene. Recognizing the importance of unveiling signature genomics in rare diseases, we conducted a quantitative study on PAH and SMN1 proteins of multiple organisms by employing various quantitative techniques to assess genetic variations. The derived signature-genomics contributes to a deeper understanding of these critical genes, paving the way for enhanced diagnostics for disorders associated with PAH and SMN1.

The epidemiology and healthcare burden of rare diseases requiring hospitalisation among adult patients in Langkawi, Malaysia: Insights from a pilot study

In Malaysia, rare diseases affect fewer than 1 in 4,000 people. As of 2020, 491 rare diseases have been recorded in Malaysia, but with limited epidemiological data. As the first study in Malaysia, this retrospective cohort study examined the epidemiology and admission-related healthcare costs for adult rare disease patients in Langkawi. Among the 38 patients, rheumatological rare diseases topped the list (39.5%). The annual admission rate for rare diseases was 0.9%. Langkawi patients had lengthy hospital stays (9.7 days) and a 7.9% mortality rate. 23.7% of patients defaulted to follow-up, and 7.9% were referred to a tertiary hospital due to inadequate equipment or speciality care. Admission costs were Malaysian Ringgits (MYR) 244,598.63 (~US Dollars (USD) 51,280), with 80.2% from medication. The average healthcare resource utilisation was MYR 6,436.81/ patient/year (~USD 1,350/patient/year).

Current Status of Newborn Bloodspot Screening Worldwide 2024: A Comprehensive Review of Recent Activities (2020-2023)

Newborn bloodspot screening (NBS) began in the early 1960s based on the work of Dr. Robert "Bob" Guthrie in Buffalo, NY, USA. His development of a screening test for phenylketonuria on blood absorbed onto a special filter paper and transported to a remote testing laboratory began it all. Expansion of NBS to large numbers of asymptomatic congenital conditions flourishes in many settings while it has not yet been realized in others. The need for NBS as an efficient and effective public health prevention strategy that contributes to lowered morbidity and mortality wherever it is sustained is well known in the medical field but not necessarily by political policy makers. Acknowledging the value of national NBS reports published in 2007, the authors collaborated to create a worldwide NBS update in 2015. In a continuing attempt to review the progress of NBS globally, and to move towards a more harmonized and equitable screening system, we have updated our 2015 report with information available at the beginning of 2024. Reports on sub-Saharan Africa and the Caribbean, missing in 2015, have been included. Tables popular in the previous report have been updated with an eye towards harmonized comparisons. To emphasize areas needing attention globally, we have used regional tables containing similar listings of conditions screened, numbers of screening laboratories, and time at which specimen collection is recommended. Discussions are limited to bloodspot screening.

Current situation and prospect for the diagnosis and treatment of pediatric critical rare diseases in China

The onset of critical rare diseases (RDs) in children is rapid and dangerous, accompanied by a high mortality rate, which brings a heavy burden to both families and society. Multiple malformations, neuromuscular diseases, metabolic diseases, and heart diseases are the most common types of RDs in children of China, often manifesting with multiple organ dysfunction. At present, the diagnosis and treatment of critical RDs in children face challenges such as prolonged diagnosis time, a high misdiagnosis rate, limited treatment modalities, and a significant disease burden. However, with the progress in genetic testing technology, the establishment of multidisciplinary diagnosis and treatment platforms, and the implementation of relevant RD policies in China, children with critical RDs will received enhanced medical services, experience improved prognoses, and reintegrate into social life.

Understanding Challenges of Genetic Testing on Neuromuscular Disorders from the Parental Lens

Neuromuscular disorders, characterized by progressive muscle degeneration and weakness, present substantial challenges to both affected individuals and their families. Genetic testing assumes a pivotal role in facilitating early diagnosis, intervention, treatment, and informed family planning for these conditions. The objective of this qualitative study is to delve into the knowledge, awareness, and perceptions surrounding genetic testing within the cohort of parents caring for individuals with neuromuscular disorders in Malaysia. A semi-structured interview approach was employed to elicit data from parents of individuals diagnosed with neuromuscular disorders, encompassing those with clinical diagnoses and those diagnosed through genetic testing. Examination of the interview responses yielded nine overarching themes, which furnish invaluable insights into the perspectives of Malaysian parents concerning genetic testing. The study discerned several challenges associated with genetic testing, notably encompassing the limited awareness among parents, the financial constraints associated with genetic testing, and the perceived significance of genetic testing in the context of neuromuscular disorders. The findings suggest that the level of knowledge and awareness pertaining to genetic testing for neuromuscular disorders among parents in Malaysia varies, with initial levels of awareness ranging from relatively low to reasonably sufficient prior to and following the birth of an affected child. However, the investigation revealed that parents tended to cultivate more favorable perceptions regarding genetic testing subsequent to their experience with genetic counseling. This underscores the potential for heightened awareness and comprehension as a consequence of the personal experience of parenting an affected child confirmed through genetic testing and genetic counseling, ultimately influencing parental awareness.

Literature Review on Health Emigration in Rare Diseases-A Machine Learning Perspective

The article deals with one of the effects of health inequalities and gaps in access to treatments for rare diseases, namely health-driven emigration. The purpose of the paper is to systematize knowledge about the phenomenon of health emigration observed among families affected by rare diseases, for which reimbursed treatment is available, but only in selected countries. The topic proved to be niche; the issue of "health emigration in rare diseases" is an area for exploration. Therefore, the further analysis used text mining and machine learning methods based on a database selected based on keywords related to this issue. The results made it possible to systematize the guesses made by researchers in management and economic fields, to identify the most common keywords and thematic clusters around the perspective of the patient, drug manufacturer and treatment reimbursement decision-maker, and the perspective integrating all the others. Since the topic of health emigration was not directly addressed in the selected sources, the authors attempted to define the related concepts and discussed the importance of this phenomenon in managing the support system in rare diseases. Thus, they indicated directions for further research in this area.

Knowledge and perception of inborn errors of metabolism (IEMs) among healthcare students at a selected public university in Klang Valley, Malaysia

Healthcare providers play an important role in improving the health of Inborn Error of Metabolism (IEM) patients. However, IEM knowledge level among local healthcare students has yet to be determined. Thus, the aim of this study is to assess the knowledge and perception of IEM among local healthcare students. An online self-administered questionnaire was distributed to 378 students across the Faculty of Health Science, Pharmacy and Dentistry from a selected public university in Lembah Klang, Malaysia. For knowledge, a score of 1 is assigned to each correct answer with a maximum total score of 14. Likert scale was used to determine their perception of IEM. The total mean score of IEM knowledge among healthcare students is 5.8. There was no significant difference of mean score of IEM knowledge among the students from the Faculty of Health Science (6.1 ± 2.7), Pharmacy (5.5 ± 2.6) and Dentistry (5.8 ± 2.8). However, the score of knowledge is observed to be significantly different by ethnicity, religion and family history of IEM (p < 0.05). Furthermore, students with experience of meeting an IEM patient and attending IEM classes scored higher than those with no experience (p < 0.05). Most of the healthcare students (89.5%) perceived their knowledge to be insufficient and very poor. Majority of the students from faculty of pharmacy (70.8%) agreed that the IEM course should be mandatory compared to health sciences and dentistry (p < 0.05). This study identified an overall inadequacy of knowledge of IEM among healthcare students. There is a pressing need to improve the IEM-related knowledge and awareness of Malaysian healthcare students. This can be accomplished by incorporating online classes that emphasizes the treatment and management of IEMs in the university curriculum.

Screening of Patient Impairments in an Outpatient Clinic for Suspected Rare Diseases—A Cross-Sectional Study

Background: Most rare diseases are chronic conditions with variable impairment of functionality, which can result in a need for rehabilitation. To our knowledge, there are no systematic studies on the rehabilitation needs of patients in centres for rare diseases in the literature. Our hypothesis is that participation of these patients is so limited that there is an increased need for rehabilitation. For this reason, a survey on the need for rehabilitation was carried out in all patients presenting to the centre for rare diseases, in order to assess the need for rehabilitative measures to counteract disturbances in activity and participation. Methods: A cross-sectional study was performed to collect data using a written questionnaire from December 2020 to June 2021, including patients presenting personally in the center for rare diseases. Results: Nearly 70% of the participants assessed their own ability to work as critical. Of those surveyed, n = 30 (44.9%) had PDI total ≥ 33 points and, thus, a clear pain-related impairment. Conclusion: The results show functional restrictions in the areas of mental well-being and activity. As expected, the health-related quality of life is reduced as compared to healthy people. Almost half of the participants reported significant pain-related impairments, however, only 9% of all respondents stated that they had received appropriate pain therapy. The results show the need for rehabilitation-specific skills in the care and counseling of patients with rare diseases.

Exploring the Barriers and Motivators to Dietary Adherence among Caregivers of Children with Disorders of Amino Acid Metabolism (AAMDs): A Qualitative Study

Dietary intervention is generally accepted as the mainstay of treatment for patients with disorders of amino acid metabolism (AAMDs). However, dietary adherence to a low-protein diet is always reported as a common challenge among these patients. This study explored the perception of barriers and motivators to dietary adherence among caregivers of AAMD patients in Malaysia. Twenty caregivers of children with AAMDs receiving ongoing treatment at the genetic clinic participated in an online focus group discussion from November to December 2021. Findings showed a total of five interrelated main themes identified from focus group discussion (FGD) exploring parents’ experiences related to the management of their child’s daily diet. The barriers to dietary adherence were burden of dietary treatment, diet and dietary behavior, parenting challenges, limited knowledge related to dietary treatment, and challenges in healthcare system delivery. Key factors facilitating good dietary adherence include good knowledge of dietary treatment, parental coping strategies, social coping, and dietary behavior. In conclusion, despite the existence of several barriers to the implementation of dietary treatment, caregivers managed to use a wide range of coping strategies to overcome some, if not all, of the challenges. The important next step is to develop, in conjunction with multidisciplinary healthcare professionals, feasible implementation strategies that could address these barriers and at the same time improve the quality of life of caregivers.

A comparison of self-evaluated survey and work sampling approach for estimating patient-care unit cost multiplier in genetic nursing activities

PURPOSE

To compare patient care multipliers estimated from subjective evaluation against work sampling techniques in genetic nursing activities.

METHODS

An observational work sampling technique was conducted from November to December 2019 with nine genetic nurses in a tertiary referral centre in Malaysia. The work sampling activity instrument was devised, validated, and pilot tested. All care and noncare-related activities were sampled at 10-minute intervals within 8 hours of working over 14 days, followed by a subjective evaluation of activities survey over the same period. Bonferroni correction was undertaken for multiple testing with a p value of 0.0025.

RESULTS

The two techniques produced significant differences in genetic nurses' activities categorization. The work sampling showed that compared with subjective evaluation, direct care (19.3% versus 45.0%; p < .001) was estimated to be significantly lower, and indirect care (40.4% versus 25.6%; p < .001) and unit-related care (28.5% versus 16.9%; p < .001) were higher. Both techniques produced a similar proportion of time spent in other noncare activities (12.0%) but differed in genetic meetings and information-gathering activities. While the multipliers for patient face-to-face contact were significantly larger between work sampling (4.57) and the survey (1.94), the multipliers for patient care time were smaller between work sampling (1.47) and the survey (1.24), indicating that caution should be taken when multiplying for patient contact time compared to patient care activity to determine the cost of care provision.

CONCLUSION

A considerable proportion of time spent away from the patient needs to be allocated to patient-related care time. Thus, estimating the paid cost solely based on direct time with patients considerably underestimates the cost per hour of nurses' care. It is recommended to employ 'patient-related activity' instead of the 'face-to-face contact' multiplier because the former did not significantly differ from the one estimated using work sampling.

A mixed method study on the impact of living with spinal muscular atrophy in Malaysia from patients’ and caregivers’ perspectives

Background

Spinal Muscular Atrophy (SMA) is a rare, recessively inherited neuromuscular disorder that causes progressive muscle weakness. There is a low degree of awareness about SMA amongst the public and healthcare providers, which may impact the perception of the disease and its proper management. To understand how this lack of awareness may have affected diagnosis, care and support for SMA patients and their caregivers, this study aims to investigate the impact of SMA on the lives and daily activities of SMA patients and their caregivers in Malaysia.

Methods

Nationwide recruitment was carried out via invitations coordinated by a local SMA advocacy organization. A mixed method cross-sectional study consisting of a self-administered questionnaire followed by in-depth interviews (IDIs) and focus group discussions (FGDs) was conducted. The interview sessions were audio-taped, and verbatim transcripts analyzed thematically.

Results

Participants reported feeling stressed, anxious and depressed. There were issues with delayed diagnosis, lack of information from healthcare professionals about the disease progression, and limited access to supportive services like physiotherapy. Participants expressed their concerns living with self-doubt and turmoil with having to modify their lifestyles, relationships with family and friends, and challenges with educational and career opportunities. Various themes of their hopes for the future touched on having access to treatment, clinical trials, holistic care for symptom management, as well as improving infrastructure for disability access.

Conclusion

This study, to the best of our knowledge represents the first comprehensive study on SMA in South East Asia, highlights a plethora of issues and challenges experienced by persons with spinal muscular atrophy (PWSMA) and their caregivers in Malaysia, from the point of SMA diagnosis and throughout the management of care, in addition to the deep psychosocial impact of living with SMA. The significant findings of this study may contribute to a better understanding among stakeholders to make improvements in clinical practice, the education system, the work environment as well as holistic care support and society at large.

Stakeholders' Views on Patient Access Schemes in Malaysia

OBJECTIVES

The healthcare system aspires to ensure improved access to treatment while working within the existing financial constraints and increasing demands. Patient access schemes (PASs) are initiated to improve access. This study seeks the stakeholders' views on the PAS in the public healthcare sector in Malaysia.

METHODS

This is an exploratory qualitative study using a web-based online survey and semistructured interviews. The participants were recruited by purposive sampling, where the Ministry of Health of Malaysia staff, pharmaceutical organization personnel, and patient advocacy organization personnel with experience in PAS were invited to participate. A total of 42 consenting participants answered the survey, whereas the face-to-face interview had 8 participants. Interviews were thematically analyzed using the qualitative data analysis software NVivo V.12. The Medical Research and Ethics Committee, Ministry of Health of Malaysia, approved the study.

RESULTS

Only finance-based PAS was reportedly implemented, and it covered drugs for antineoplastic or immunomodulating therapy, alimentary tract and metabolism, sensory organs, and systemic hormonal preparations. A total of 3 major themes were identified. High upfront cost and high budget impact are a major concern leading to the need for PAS. Identifying the treatment needs was a major concern as well. The readiness of the health system to implement PAS will determine whether the PAS can be successfully implemented. Challenges similar to other jurisdictions were observed in Malaysia, concerns on data availability, the responsibility of the stakeholders, and the need for a legal framework.

CONCLUSION

Most stakeholders responded positively that the PAS would grow. Trust among stakeholders and a structured access plan would enhance the implementation and ensure its success.

Current Scenario of Clinical Diagnosis to Identify Inborn Errors of Metabolism with Precision Profiling for Expanded Screening in Infancy in a Resource-limited Setting

Inborn errors of metabolism (IEM) are a diverse collection of abnormalities that cause a variety of morbidities and mortality in children and are classified as uncommon genetic diseases. Early and accurate detection of the condition can save a patient's life. By aiding families as they navigate the experience of having a child with an IEM, healthcare practitioners have the chance to reduce the burden of negative emotional consequences. New therapeutic techniques, such as enzyme replacement and small chemical therapies, organ transplantation, and cellular and gene-based therapies using whole-genome sequencing, have become available in addition to traditional medical intake and cofactor treatments. In the realm of metabolic medicine and metabolomics, the twentyfirst century is an exciting time to be alive. The availability of metabolomics and genomic analysis has led to the identification of a slew of novel diseases. Due to the rarity of individual illnesses, obtaining high-quality data for these treatments in clinical trials and real-world settings has proven difficult. Guidelines produced using standardized techniques have helped enhance treatment delivery and clinical outcomes over time. This article gives a comprehensive description of IEM and how to diagnose it in patients who have developed clinical signs early or late. The appropriate use of standard laboratory outcomes in the preliminary patient assessment is also emphasized that can aid in the ordering of specific laboratory tests to confirm a suspected diagnosis, in addition, to begin treatment as soon as possible in a resource limiting setting where genomic analysis or newborn screening facility is not available.

Budget Impact of Emicizumab for Routine Prophylaxis of Bleeding Episodes in Patients With Hemophilia A With Inhibitors

OBJECTIVES

To examine the budget impact of emicizumab as prophylactic therapy in reducing the frequency of bleeding episodes in patients with hemophilia A with inhibitors in Malaysia.

METHODS

A budget impact model was built to assess the cost implication of introducing emicizumab for routine prophylaxis of bleeding episodes in people with hemophilia A with inhibitors. It was based on the public healthcare system in Malaysia over a 5-year duration. The primary analysis computed healthcare costs for emicizumab compared with no prophylactic regimen to calculate the budget needed to treat all patients with hemophilia A with inhibitors.

RESULTS

The introduction of emicizumab resulted in a total incremental budget of Malaysian Ringgit (RM) 20 356 897 ($4 917 125) during the first year. The total cost for the current situation (no prophylaxis) was RM13 425 941 ($3 242 981), whereas the total cost for the new situation (prophylaxis with emicizumab) was RM33 782 838 ($8 160 106). The 5-year cumulative incremental budget impact from 2021 to 2025 was RM97 205 459 ($23 479 579) with an uncertainty range from -RM4 869 886 (-$1 176 301) to RM138 035 597 ($33 341 932) and a total of 72 patients treated with emicizumab. In a sensitivity analysis, the use of emicizumab was cost saving if the annual bleeding rate was greater than 16 instead of 6 times per year.

CONCLUSION

The 5-year budget impact might be considered reasonable and possibly cost saving. The model and approach used in this study to obtain relevant parameters where scarce data exist may help other jurisdictions with future adaptation.

Rare disease patients’ needs: an up-to-date analysis and future directions

The interest to rare diseases has increased in the recent decades. Legislation seeks to facilitate patients’ access to innovative and effective treatment and to define incentives for pharmaceutical and biotechnology companies to develop new medicines for rare diseases.The current review presents the current knowledge and adopted solutions in the field of rare diseases and discusses the future issues and unmet needs that should be resolved for affected patients and their families. Along with the positive trends in the field of rare diseases, there are still issues related to diagnosis and inequal care for some patients groups that should be solved over the next decade. The innovative digital health methods, which have been improved continuously in the recent years, implementation of improved versions of patient-centered policy plans and programs and investment in advanced therapies could move forward the rare diseases to new horizons giving them the opportunity to overcome the main barriers and challenges in the whole journey of the patients – from diagnosis through treatment to follow-up.

Emotional experience of the diagnostic process of a rare disease and the perception of support systems: A scoping review

AIMS AND OBJECTIVE

To explore the experience of adult patients and adult patients' families, and their perception of the support systems received during the diagnostic process of rare diseases.

BACKGROUND

There are about 7,000 rare diseases that affect 7% of the world's population. Rare diseases are often underdiagnosed. This has been reported to have deleterious physical and psychological consequences in both the patients and their families, especially when institutional support during this process is low.

DESIGN

A scoping review was carried out following the 6-phase model proposed by Arksey & O'Malley and Levac et al., including the consultation phase in which patients diagnosed with rare diseases were interviewed to seek their views on the bibliographic evidence reviewed and their experience during the diagnostic process.

METHODS

The databases consulted were PubMed, CINAHL, Web of Science, SCOPUS, Cochrane Library, PsycINFO, OpenGrey, ProQuest Dissertations and Theses Global. They were explored from inception-July 2020, and qualitative, quantitative and mixed method studies were included. The Mixed Methods Appraisal Tool was used for the critical evaluation of the articles. The review was based on the guidance in the PRISMA-ScR statement.

RESULTS

The initial search identified 2,350 articles, of which 20 fully met the inclusion criteria and were therefore reviewed. In this analysis appeared two dimensions: internal factors: emotional aspects, and external factors: resources and support systems.

RELEVANCE TO CLINICAL

This review provides evidence on the emotional impact of the diagnostic process and during the communication phase of the definitive diagnosis. Health systems and professionals must be strengthened in order to improve the information, training and resources. Nurses can play a key role in coordinating communication and follow-up of those affected.