key: cord-0693508-fon4l1kh
authors: Amaran, Safiya; Kamaruzaman, Ahmad Zulfahmi Mohd; Mohd Esa, Nurul Yaqeen; Sulaiman, Zaharah
title: Malaysia Healthcare Early Response in Combatting COVID-19 Pandemic in 2020
date: 2021-11-20
journal: Korean J Fam Med
DOI: 10.4082/kjfm.20.0117
sha: 723b0eb05c26ef0bee6a04b7b795a553b9c72427
doc_id: 693508
cord_uid: fon4l1kh

The year 2020 saw the emergence of a novel coronavirus—the severe acute respiratory syndrome coronavirus 2—which has led to an unprecedented pandemic that has shaken the entire world. The pandemic has been a new experience for Malaysia, especially during the implementation of large-scale public health and social measures called the Movement Control Order (MCO). This paper seeks to describe the experiences of the Malaysian healthcare system thus far in combatting the pandemic. The Malaysian healthcare system comprises two main arms: public health and medicine. The public health arm focuses on early disease detection, contact tracing, quarantines, the MCO, and risk stratification strategies in the community. The medical arm focuses on the clinical management of coronavirus disease 2019 (COVID-19) patients; it encompasses laboratory services, the devising of clinical setting adjustments, and hospital management for COVID-19 and non-COVID-19 patients. Malaysia experienced intense emotions at the beginning of the pandemic, with great uncertainty regarding the pandemic’s outcome, as the world saw a frighteningly high COVID-19 mortality. As of writing (May 30, 2020), Malaysia has passed the peak of its second wave of infections. The experience thus far has helped in preparing the country’s healthcare system to be vigilant and more prepared for future COVID-19 waves. To date, the pandemic has changed many aspects of Malaysia’s life, and people are still learning to adapt to new norms in their lives.

The emergence of a novel coronavirus-the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)-has startled the entire world.

A novel virus means every human being is susceptible to infection, as no one yet has developed immunity against it. Hence, anyone can get infected with coronavirus disease 2019 (COVID-19) if exposed to it. In particular, the fatality rate of the disease is significantly higher among the elderly and among people with comorbidities. 1 implemented a total lockdown called cordon sanitaire, which has been described as "the largest quarantine in human history. " 3) The lockdown was implemented in Wuhan on January 23, 2020, and similar restrictions were later extended to 15 cities in the rest of Hubei province-affecting approximately 57 million people-to suppress the pandemic. 4) Authorities immediately prepared 16 temporary hospitals in response to a sudden massive demand for healthcare services due to the large number of cases. 5) The high number of COVID-19 cases and mortality in Wuhan was especially frightening, and countries worldwide were observing China while making their own preparations. The COVID-19 outbreak was declared by the World Health Organization (WHO) as a "public health emergency of international concern" on January 30, and was later announced as a pandemic on March 11, due to rapid increase in the number of cases involving a growing number of countries.

The Malaysian healthcare system began to prepare for COVID -19 since it first emerged in Wuhan. A preparedness plan was initiated by Ministry of Health Malaysia since early January 2020, which covered preparations in areas encompassing public health, clinical management, and laboratory capacity. COVID-19 screening using thermal scanners was implemented at all international points of entry in Malaysia. 6) As of May 2020, there are 79 thermal scanners located throughout Malaysia. 7) With these scanners, visitors with a fever can be detected and checked for other respiratory-related symptoms. Nonetheless, despite thorough gatekeeping procedures, infected persons may pass undetected if they are afebrile and show no such symptoms. At the beginning of the pandemic, 57 hospitals were initially prepared for con-ducting COVID-19 screenings, and 28 hospitals were allocated for receiving and treating COVID-19 patients, with at least one hospital per state. In terms of diagnostic tests, the Institute for Medical Research (IMR) prepared employment of the reverse transcriptase polymerase chain reaction (RT-PCR) test to diagnose COVID-19 from the SARS-CoV-2 genome sequence that has been shared by China. With this test, authorities in Malaysia are able to detect a person carrying the SARS-CoV-2 virus. In the initial stage of the pandemic, the IMR was the only laboratory involved in conducting RT-PCR testing in Malaysia, which is the gold standard for testing widely used globally.

In January 2020, travelers from China were still allowed to enter Malaysia, but anyone from Wuhan with any symptoms of COVID-19 immediately had to be screened for the virus in designated screening centers, which was how the country's initial cases were detected. The pandemic in Malaysia started as a small wave on January 25 in Johor Bharu, when three individuals who traveled from Wuhan tested positive for the coronavirus. 8) All cases were admitted and treated accordingly in the isolation ward despite their mild symptoms; some COV-ID-19 cases have very mild symptoms but are still admitted to the isolation ward to prevent further spread of the virus.

Contact tracing was initiated following the detection of positive cases in Malaysia as an immediate control and preventive measure. If a person is known to have been in close contact with a confirmed case, the local district health office requires that the person quarantines for 14 days, according to the average incubation period of COVID-19 reported by the WHO. 1) Adherence is compulsory under the Control and Prevention of Infectious Diseases Act, 1988. If a close contact has a fever or other respiratory-related symptoms, he or she is defined as a person under investigation (PUI) and needs to be hospitalized for further clinical management. 9)

The first COVID-19 case involving a Malaysian was detected on February 5, 2020. Further investigation by Johor State Health Department found that the person infected could have contracted the disease while attending an event in Singapore, which included participants from Wuhan. The cluster that emerged as a result of this event marked the beginning of local transmission in the country, when the infected Malaysian's family members also became infected. Since the case's detection, the surveillance system of Malaysia has been strengthened to monitor daily and weekly trends in all sentinel health centers in the country. The surveillance includes looking for influenza-like illness (ILI) in health clinics and severe acute respiratory illness (SARI) in government hospitals. 10) Reported cases remained relatively low throughout February 2020 until a large spike of cases became apparent in the middle of March and March 2, 2020 and attended by nearly 15 thousand people, including local and international participants. 12) During this religious gathering, participants engaged in many activities together, confined to the mosque. Their activities included interacting directly with each other, eating, praying, and sleeping together in the mosque for four consecutive days. The attendees shared many areas, such as toilets, dining areas, and sleeping areas. Although the mosque is large, the number of large attendees made it relatively crowded.

A number of other mass gatherings also occurred in Malaysia in early March 2020, as this was still allowed at the time; however, only the Tabligh gathering led to significant disease transmission, probably due to all the risks explained above. The local attendees were from all states in Malaysia, which resulted in the spread of the virus throughout the country when attendees returned home. The fact that nobody was aware that COVID-19 spread among the Sri Petaling attendees and their close contacts allowed the disease to spread insidiously in the local community throughout Malaysia, including Sabah and Sarawak ( Figure 2 ). 13) 

Since the country's Ministry of Health identified the Tabligh event as a potential COVID-19 spreading event, Malaysia has picked up more COVID-19 secondary cases via contact tracing from the Sri Petaling cluster. The control measure for the Sri Petaling cluster was laborious, as the participants of the event were scattered throughout the country.

However, with good cooperation with the head of the Tabligh organization and religious councils, contact tracing and active case detection were manageable. As of May 29, 2020, there were 3,370 positive cases out of 41,320 persons screened (8.16% yield); the Sri Petaling cluster has contributed 43.5% to the total number of COVID-19 cases in Malaysia. 13) As for international travelers, all Malaysian citizens who have returned from abroad are quarantined and monitored upon arrival for 14 days. Malaysia has prepared 409 quarantine centers throughout Malaysia capable of accommodating 40 thousand inhabitants at any one time. 14 

Quarantine is not an ordinary day-to-day health measure in Malaysia; the last time it was widely used was during the H1N1 pandemic in 2009. 15) Hence, many of those currently covered by this health measure are experiencing it for the first time. Some of those affected cannot fully understand the quarantine orders and mingle with their family members as usual. Quarantines lead to emotional distress and anxiety for some people, and these psychological responses have also been reported in other countries. 16, 17) To alleviate this problem, during quarantine, a psychosocial assistant is provided to those in need by the relevant healthcare workers.

Amid the pandemic, many countries across the world including China, India, Italy, and the United Kingdom have relied on lockdowns as a public health and social measure to suppress the spread of COV-ID-19. [18] [19] [20] [21] Even so, while millions across the world are confined to their homes, offices and businesses are shut, and economies are on the verge of collapse, Sweden and South Korea have not followed others in locking down their residents. 22) In response to the COVID-19 pandemic, South Korea introduced an extensive screening program for early detection and the systematic tracing and quarantine of closecontacts of infected individuals. 23) South Korea's screening program has proved to be successful, as its COVID-19 mortality rate is just five per million population. 24) In contrast, for Sweden, in the absence of a lockdown, its COVID-19 mortality rate per million population is currently among the top ten highest in the world, at 452 per million population. 24) Malaysia implemented a limited lockdown following an exponential 

Apart from the MCO, the Malaysian government has implemented a risk stratification strategy based on the number of confirmed cases compared with states and districts. The strategy uses a color-coded mechanism, segregating the number of cumulative confirmed cases according to traffic light colors: green means the district does not have any confirmed cases, white means the cases are from one to 19, orange means there are 20 to 40 cases, and red marks the 40-case threshold.

As of early May 2020, 27 districts in Malaysia have been classified into red zones at least once. 9) To further enhance the risk stratification strategy, it has been improvised from the cumulative case approach to the active case approach. Active cases refer to the total number of cases minus the number of discharged and deceased cases. As shown in cases. 26) In certain localized hotspots, the enhanced MCO (EMCO) is applied when a cluster of cases is found, without setting any threshold number of positive cases in a certain place. The decision to implement the EMCO depends on the National Security Council, with advice from the Ministry of Health Malaysia. The EMCO mimics a total lockdown, in which inhabitants are not allowed to leave their homes. Food supplies and basic amenities are provided by the government. The EMCO allows contact tracing and screening to be carried out more efficiently, resulting in faster and more effective pandemic control. 27) As of early May, six localized hotspots have been identified. 28) As a whole, the MCO was implemented for more than 6 weeks before it was eased into the Conditional MCO (CMCO) on May 4, 2020.

The prime minister announced the shift to the CMCO as being effective until June 9, which has allowed the reopening of certain areas of the economy, free movement, and social activities, except for mass gatherings and interstate traveling. The CMCO received different reactions from various states in Malaysia. Six states (Sabah, Sarawak, Kedah, Penang, Pahang, and Kelantan) initially chose to defer the implementation of the CMCO, pending further study on the state of COV-ID-19 in their territories. Selangor, the country's most developed state, has largely followed the relaxed CMCO and reopened businesses, prohibiting only dining in at eateries and closing a few public parks despite having the second-highest number of COVID-19 cases in Malaysia ( Figure 1 ). 13) Negeri Sembilan, one of Malaysia's states, has also reopened certain economic sectors, but will maintain restrictions on social activities; businesses are not allowed to resume in areas with new coronavirus cases. 29) 

Unlike the public health approach, which is entirely under the public's domain, Malaysia has a dual-tiered system of clinical management services: a government-led sector funded by the public sector and a private sector, creating a dichotomous yet synergistic public-private model. Both sectors have been affected and are involved in managing the COVID-19 pandemic to meet the healthcare needs of the nation.

While the public sector manages the inpatient COVID-19 cases, the private sector covers for the spillover cases from government hospitals, and both public and private sector laboratories are extensively utilized in screening and diagnostic tests. Collaboration and a specific arrangement have also been implemented between public and private healthcare practitioners, whereby non-COVID-19 cases from government hospitals can be transferred to private hospitals, with private doctors providing clinical services free of charge or "pro bono. " This has further eased the burden of public healthcare practitioners in combating CO-VID-19. 30) 

At the government hospital level, during the first wave of the outbreak, At the private hospital level, major modifications have been made in terms of relocation of staff and wards to comply with the isolation protocol for COVID-19 patients and suspects. Specific wards have been designed to cater to potential COVID-19 patients while waiting for laboratory test results. If a patient is confirmed to be negative for COV-ID-19, the patient will be transferred from the isolation ward to a normal ward. If a patient tests positive, the patient is immediately transferred to a designated COVID-19 government hospital. Drive-through testing services have also been initiated in many private hospitals to accommodate for massive screening approaches by the government. 32) 

Since COVID-19 first emerged, the Malaysian guidelines for disease management have been frequently updated to cope with the dynamic nature of the pandemic. The definition of a PUI has been iteratively amended to capture different categories of high-risk individuals. 33 Malaysian Thoracic Society has also come up with specific guidelines for the inhalational protocol for asthma and chronic obstructive pulmonary disease COVID-19 patients, as it is no longer advisable to rely on nebulizers amid the pandemic. 35) In terms of COVID-19 treatment, few antiviral therapies have been used per compassionate use, as many randomized controlled trials for treatment drugs are ongoing. The drugs that are being used in Malaysian COVID-19 hospitals include hydroxychloroquine, chloroquine, remdesivir, ribavirin, interferon beta 1b, and Kaletra (lopinavir/ritonavir). Plasma therapy is currently being explored as an avenue for treatment, as per an April 4, 2020 health report. 36) 

The pandemic has also led to an increase in telemedicine between doctors and patients. During the MCO, non-COVID-19 patients were restricted from attending non-emergency clinic appointments, as many clinics re-scheduled their appointments to prevent further spread of the virus. Patients have also been apprehensive of going to the hospital because of the risk of contracting the virus from the hospital and other high-risk patients. Hence, some government and private hospitals have come up with telemedicine as a medium for health practitioners to see their patients via a "virtual clinic" at the comfort of the patient's home. This facility has been found to be useful among non-critical patients who need to review their medications and follow up with their respective doctors and who do not need a thorough physical examination and extensive investigation. The facility has also been found to help alleviate patients' anxiety and address their health concerns, especially pertaining to COVID-19 and their diseases. Certain specialties that require much communication between doctors and patients have benefited from this program, especially psychiatry. However, among the pitfalls of telemedicine, it is not suitable for certain diseases that require specific and thorough examinations, such as ophthalmology, neurology, cardiology, gastroenterology, and other surgical-based conditions. For essential medical conditions that require physical hospital visits, the seats and tables of consultation clinics have to be arranged at one-meter distances as per Malaysian National Security

In terms of diagnostic tests, the RT-PCR test is the gold standard for diagnosing COVID-19 and is widely used globally because of its high accuracy rate. A swab is taken from either an individual's nasopharyngeal or oropharyngeal area, and the RT-PCR laboratory procedure usually takes 24 hours to complete. In the initial stage of the pandemic, the IMR was the only laboratory involved in diagnosing COVID-19, but capacity has since been expanded and strengthened to include 44 laboratories from the public, universities, and the private sector to meet demands. Malaysia's testing capacity for COVID-19, which currently stands at 11,500 samples per day, is expected to increase with the expected addition of five new laboratories. 33, 37) These five facilities will be located in Tawau, Sandakan, Miri, Bintulu, and Kluang; soon, there will be 48 testing facilities nationwide. The ministry has targeted the achievement of 16,500 tests per day by mid-April. 38) As of March 2020, the use of a faster antigen-based rapid test kit has not been endorsed owing to its low sensitivity. Thus, reliance with regard to tests is still on the RT-PCR test, resulting in a bottleneck scenar- Awareness regarding the lack of PPE and medical instruments has also been high among Malaysians, which has led to many donation drives, initiated by royalty, non-government organizations (NGOs), PPE, donations have also included financial support and technical support tools such as tents, air-conditioners, air purifiers, and thermal scanners, as well as disposable hijabs for female Muslim healthcare workers, and these initiatives have lifted some healthcare burdens. 44) The Malaysian queen has donated 100 beds to Hospital Sungai Buloh and 50 beds to Hospital Kuala Lumpur, 45) 

COVID-19 is unprecedented. Never has a pandemic of this scale and severity occurred in recent years. The entire world is fighting a pandemic more severe than the 1918 pandemic, which killed approximately 20 to 40 million people worldwide. 49) The main goal of COV-ID-19 public health strategies to suppress transmission and reduce mortality has largely been achieved through the implementation of large-scale public health and social measures. Since a vaccine or cure for COVID-19 has yet to be identified in May 2020, the importance of these traditional public health measures has greatly been evident.

As of the time of writing (May 30, 2020), Malaysia has experienced two COVID-19 waves (Figure 1) , 13) the latter of which was bigger and persisted for more than 2 months, resulting in 7,732 cases with 115 deaths (1.5%). Malaysia has passed the peak of the curve, and 80.64% of confirmed cases have recovered ( Figure 6 ). 13 large second wave has been a great relief to everyone. As of the time of writing, the MCO has been implemented for more than 6 weeks. This 6-week duration is crucial, as it buys some time for the healthcare system to gradually increase its capacity and allows healthcare staff to gain important experience in dealing with the pandemic. All this experience has prepared them emotionally and physically if further waves are going to recur, as predicted by the WHO.

At the end of May, it was obvious that COVID-19's mortality rate in Malaysia would not follow the rate in Italy (Figure 7) . 13, 39) 

After extensive public health and social measures, Malaysia has managed to reduce the number of active COVID-19 cases nationwide, and the situation in the country has become more manageable ( Figure   6 ). 13) The Ministry of Health has managed to detect many clusters and further identified a vulnerable group that had a higher risk of contracting COVID-19. As of May 29, 2020, the largest cluster in Malaysia has been the Sri Petaling (Tabligh) cluster, with 3,370 cases ( Figure 8 ). 13) Other clusters have been relatively smaller, with no more than 300 cases for each cluster (Figure 9 ). 13) The Bukit Jalil IDD cluster included un- Currently, the Ministry of Health Malaysia continues to actively screen migrant workers ( Figure 10 ). 13 

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No potential conflict of interest relevant to this article was reported.