2022
TECHNICAL REPORT
KEDAH STATE HEALTH DEPARTMENT
Kedah State Health Department Technical Report
2022
Copyright Kedah State Health Department
(Jabatan Kesihatan Negeri Kedah)
All rights reserved. No part of this publication may be reproduced,
distributed, or transmitted in any form or by any means, including
photocopying, recording, or other electronic or mechanical methods,
without the prior written permission of the publisher, except in the case
of brief quotations embodied in critical reviews and certain other non-
commercial uses permitted by copyright law.
First printing, 2022.
Published by:
Kedah State Health Department
Simpang Kuala. Jalan Kuala Kedah
05400 Alor Setar
Kedah darul Aman
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TABLE OF CONTENT 6
EDITORIAL BOARD
FOREWORD 8
PREFACE 9
1. CONTAINING A SUBURB: MASSIVE OUTBREAK AT RELAU, A SUBURB
OF BANDAR BAHARU DISTRICT IN KEDAH STATE OF MALAYSIA 10
2. SEMI-ENHANCED MOVEMENT CONTROL ORDER (SEMCO): AN 22
APPROACH IN COMBATING PANDEMIC COVID-19 IN TAMAN DESA
BIDARA, KUALA KETIL, BALING, KEDAH
3. RISK FACTORS OF SEVERE CLINICAL OUTCOME COVID-19 CASES IN
KULIM, KEDAH BETWEEN AUGUST AND DECEMBER 2021 36
4. PEMERKASAAN KOMUNITI: PERSEDIAAN UNTUK HIDUP BERSAMA
VIRUS COVID 19! 49
5. PREDICTORS OF COVID-19 BROUGHT-IN-DEAD CASES IN KUALA MUDA
DISTRICT 57
6. COVID-19 ASSESSMENT CENTER (CAC) OF KUALA MUDA, KEDAH: 67
TRANSIT BAY IN CAC- A SAVIOR IN CRISIS MANAGEMENT DURING
COVID-19 PANDEMIC
7. CORONAVIRUS DISEASE (COVID-19) CLUSTER AMONG MIGRANT
WORKERS AT A LOCAL FACTORY IN KEDAH STATE OF MALAYSIA IN
2021 79
8. CHALLENGES IN DAH KUALA JERLUN COVID-19 CLUSTER
CONTAINMENT: HIGHLIGHTING PUBLIC HEALTH APPROACH TACKLING
PERSONS WHO INJECT DRUGS 85
9. COVID-19 MORTALITY CASES IN KUBANG PASU DISTRICT: A 95
DESCRIPTIVE STUDY
10. STRENGTHENING OF GATESCREENING & STANDARD OPERATING
PROCEDURE (SOP): A LESSON LEARN FROM CROSS-SECTIONAL
STUDY ON COVID-19 OUTBREAK AT TRAINING INSTITUTION KUBANG
PASU DISTRICT 109
11. RAPID CONTAINMENT OF COVID-19 OUTBREAK- LEARNING
EXPERIENCE FROM OUTBREAK MANAGEMENT IN HIGHER EDUCATION
INSTITUTIONS IN PADANG TERAP. 119
12. PENULARAN COVID-19 DI SEBUAH INSTITUSI PENGAJIAN, KLUSTER
DEDAP: KEPENTINGAN ASPEK PEMATUHAN AMALAN NORMA BAHARU
DI INSTITUSI PENGAJIAN 131
13. IMPAK PANDEMIK COVID-19 TERHADAP PENGGUNAAN 143
PERKHIDMATAN PERGIGIAN PRIMER DI NEGERI KEDAH
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14. PUBLIC AWARENESS & PERCEPTION ON PHARMACY VALUE ADDED
SERVICES (PVAS) BEFORE & DURING COVID-19 PANDEMIC IN KEDAH,
MALAYSIA 152
15. PUSAT PEMBERIAN VAKSIN (PPV) MEGA SPORTS ARENA AMANJAYA
TONGGAK IMMUNITI KELOMPOK KUALA MUDA 165
16. PSV IN KUALA MUDA: A SUCCESS STORY 175
17. FACTORS ASSOCIATED WITH MATERNAL COVID-19 IN KULIM DISTRICT,
KEDAH. 184
18. COVID-19 VACCINE HESITANCY AMONG ANTENATAL MOTHERS IN
KEDAH: A DESCRIPTIVE STUDY 195
19. MENJEJAKI KUMPULAN CICIR VAKSIN COVID-19 DALAM DAERAH SIK:
DAPATAN DARIPADA PROGRAM “PICK-OUTREACH” 206
20. COVID-19: KEPERLUAN SOKONGAN PSIKOSOSIAL DI KUALA MUDA 223
21. IMPACT OF COVID-19 PANDEMIC ON GLYCAEMIC CONTROL IN TYPE 2
DIABETES MELLITUS PATIENTS AT KLINIK KESIHATAN PENDANG 231
22. INTERVENSI PENGURUSAN BERAT BADAN DALAM KALANGAN 243
PENJAWAT AWAM PEJABAT KESIHATAN DAERAH SIK SECARA
VIRTUAL KETIKA PANDEMIK COVID 19
23. STATUS KESIHATAN MENTAL DIKALANGAN PELAJAR YANG MENJADI
KONTAK RAPAT JANGKITAN COVID-19: KLUSTER DEDAP 255
24. PROGRAM MAYA PROMOSI & PENCEGAHAN MASALAH PEMAKANAN
NEGERI KEDAH: CABARAN DAN KEJAYAAN SEMASA PANDEMIK COVID
19 261
25. PROGRAM BANTUAN SUSU TEPUNG PENUH KRIM BAGI MENANGANI
MASALAH BANTUT DALAM KALANGAN KANAK-KANAK SEMASA
PANDEMIK COVID-19 DI DAERAH PENDANG, KEDAH 273
26. EPIDEMIOLOGI KES COVID-19 DI KALANGAN PETUGAS PERGIGIAN DI
NEGERI KEDAH BAGI TAHUN 2020-2021 283
27. COMPARISON OF HEALTHCARE ASSOCIATED AND NON-HEALTHCARE
ASSOCIATED COVID-19 INFECTION AMONG HEALTHCARE WORKERS IN
KEDAH 290
28. WILLINGNESS TO PAY (WTP) FOR SALIVA TEST KIT AMONG 300
HEALTHCARE WORKERS IN KEDAH
29. ISLAND HEALTH: PREVALENCE OF COVID-19 INFECTION AMONG
HEALTHCARE WORKERS IN LANGKAWI DISTRICT 309
30. “BURNOUT” DALAM KALANGAN PETUGAS KESIHATAN PEJABAT
KESIHATAN DAERAH (PKD) DAN IBU PEJABAT JABATAN KESIHATAN
NEGERI (IPJKN) KEDAH SEMASA PANDEMIK COVID-19 316
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31. SISTEM GAS PERUBATAN DALAM MENANGANI PANDEMIK 326
32. PATIENT SAFETY CULTURE AND ITS DETERMINANTS AMONG
HEALTHCARE PROFESSIONALS AT A CLUSTER HOSPITAL IN KEDAH.
333
33. CABARAN PETUGAS KESIHATAN DALAM PENGURUSAN BANDUAN
POSITIF COVID-19 DI PUSAT KUARANTIN DAN RAWATAN COVID 19
(PKRC) PENJARA ALOR SETAR (KLUSTER TEMBOK) 353
34. MAKESHIFT TREATMENT CENTRE PENJARA POKOK SENA 362
MEMBENDUNG PENULARAN WABAK COVID-19 BAGI KLUSTER
TEMBOK DI NEGERI KEDAH
35. TOCILIZUMAB FOR SEVERE COVID-19 PNEUMONIAS: CASE SERIES OF
7 PATIENTS IN HOSPITAL SULTAN ABDUL HALIM 374
36. PENGUATKUASAAN AKTA 342 DALAM KAWALAN PANDEMIK COVID-19
DI KEDAH 388
37. COVID-19 ASSESSMENT OF DEFAULTERS: ENHANCING PUBLIC 392
COMPLIANCE TO COVID-19 MANAGEMENT THROUGH INNOVATIVE
ENFORCEMENT APPROACH IN KUBANG PASU DISTRICT HEALTH
OFFICE
38. AKTIVITI-AKTIVITI DI BAWAH CAWANGAN PEMATUHAN INDUSTRI,
BAHAGIAN KESELAMATAN DAN KUALITI MAKANAN (BKKM) DI NEGERI
KEDAH SEMASA PANDEMIK COVID-19 405
39. PENCAPAIAN AKTIVITI - AKTIVITI DI BAWAH CAWANGAN
PEMBANGUNAN INDUSTRI, BAHAGIAN KESELAMATAN DAN KUALITI
MAKANAN (BKKM) DI NEGERI KEDAH SEMASA PANDEMIK COVID-19 414
40. PERSONAL PROTECTIVE EQUIPMENT (PPE) PROCUREMENT 426
MANAGEMENT EXPERIENCE IN KEDAH
ACKNOWLEDGEMENT 434
EXTERNAL REVIEWERS 435
INTERNAL REVIEWERS 436
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EDITORIAL BOARD
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Illustration by Dr. Liyanatul Najwa
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FOREWORD
DIRECTOR
KEDAH STATE HEALTH DEPARTMENT
I appreciate this opportunity to express my thought for the publication of this ‘Kedah Health
Department Technical Report 2022’. I am proud that this technical report had been
successfully published and it is my upmost hope that this department will continuously
publish the technical report in many years to come and finally become one of the
established indexed journal.
For this maiden technical report, we focus on the management of Covid-19 pandemic in
various perspective. We believe the experiences gathered by all levels and categories of
staffs during the pandemic shall be shared by all sectors namely public and private, health
and non-health and also leaders and communities for better preparedness in facing future
pandemic and health crises.
I do hope the publication of Kedah Health State Department Technical Report will also serve
as a stepping stone for researchers within Kedah State Health Department’s various
divisions and facilities to publish their research and opportunity to advance their experience
and careers. The compilation of the various division’s technical reports can also serve as the
learning tools for those who are interested in gaining more knowledge from the research’s
platform.
Last but not least, I would like to express my gratitude for all efforts put in by the
contributing authors and the editorial board in the publication of “Kedah State Health
Department Technical Report 2022”.
Thank You.
DR OTHMAN BIN WARIJO
STATE HEALTH DIRECTOR
KEDAH STATE HEALTH DEPARTMENT
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PREFACE
CHAIRMAN EDITORIAL BOARD
KEDAH STATE HEALTH DEPARTMENT
I am delighted to finally present to all our readers the “Kedah State Health Department
Technical Report for 2022” after so much efforts being put in by involving parties.
Of note, it had been so many years that Kedah State Health Department unable to publish
“Kedah State Health Department Technical Report”. It had been a pride that this
department had finally came out with the publication of “Kedah State Health Department
Technical Report for 2022” in the mist of this Covid-19 pandemic. “Kedah State Health
Department Technical Report for 2022” is a compilation of technical reports from all
divisions within Kedah State Health Department, focusing on the management of the
pandemic itself from the epidemiology and clinical perspective and also the impacts of
Covid-19 pandemic to various programs under the Kedah State Health Department.
Therefore, I would like to take this opportunity to congratulate all contributing authors,
Editorial Board of Kedah State Health Department and also the Editorial Board of District
Health Offices, Hospitals and Oral Health District Offices for all the efforts that had been put
in to make the publication of “Kedah State Health Department Technical Report for 2022”
possible.
I do hope this publication would gain recognition and benefit all healthcare fraternity in
Kedah and let’s hope this department can continue to annually publish Kedah State Health
Department Technical Report in many years to come.
Thank you
DR. ISHAK BIN HUSSAIN
DEPUTY STATE HEALTH DIRECTOR (PUBLIC HEALTH)
KEDAH STATE HEALTH DEPARTMENT.
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CONTAINING A SUBURB: MASSIVE OUTBREAK AT RELAU, A
SUBURB OF BANDAR BAHARU DISTRICT IN KEDAH STATE OF
MALAYSIA
Rosnita MY1, Nur AH 1, Abdol AW 1, Ooi YS1,Rozaimah AT1, Amalina AI1
1Bandar Baharu District Health Office
*corresponding author: Amalina binti asmail@ismail, [email protected]
ABSTRACT
Background: One of the major contributing factors to evolution of COVID-19
cases is due to formation of COVID-19 clusters. The COVID-19 clusters have been
classified into different category, based on thesource of infection identified. The
study aims to explore the characteristics of COVID-19 biggest cluster and the
approach to curb the spread of the massive outbreak in Relau, a suburb of Bandar
Baharu district in Kedah State of Malaysia.
Methodology: This study is a descriptive study conducted among the 251
positive cases, the total number of Pintu Air Relau Cluster. Data was collected
from Bandar Baharu District Health Office COVID-19 data base, based on
interview during case investigation from 25 April 2021 until 13 May 2021. Data
analysis was done by SPSS version 26.0. Cases were distinguished based on age
group, gender,ethnicity, manifestation of the disease, residency, comorbidity, and
occupation.
Results: The study showed 25% of the cases aged 61-70 years old, 51.8%
affected male gender and all the positive cases are all from Malay ethnicity. 65.7%
of the positive cases developed symptoms and 72.1% of them do not have
comorbid. Most of the cases, 87.3% are the residents of Relau and half of the
cases (50.6%) mostly are not working or housewife.
Conclusions and recommendation: The highlight of the study acknowledge the
challenges to curb the spread of the COVID-19 outbreak. The characteristic of
the COVID-19 outbreak in Relau may provide a learning opportunity for a better
preparedness and public health responses in the future byexploring the pattern
of COVID-19 cases. Thus, the policymaker needs to ensure organizations are
able to respond in a timely and decisive manner during the public health crisis.
Keywords: Outbreak, COVID-19, suburb
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INTRODUCTION
A newly novel coronavirus in 2019 named, severe acute respiratory syndrome
coronavirus 2(SARS- CoV-2) caused a highly infectious respiratory disease
denominated as “coronavirus disease (COVID- 19), which has had consequential
effect on the worldwide demographic, emerging as the most significant global
health crisis. Malaysia is one the country being ravaged by COVID-19 since being
declared as global pandemic by WHO on 11 March 2020 (WHO 2020), which the
first case was reported in Wuhan, China, in late December 2019, causing
exponential increase in number of cases due its rapidly disseminated across the
world.
Extraordinary effort and strategies have been implemented by WHO and Malaysia
Ministry of Health in order to contain the spread of the diseases. One of the key
components to control the spread of coronavirus2 (SARS-CoV-2) is to understand
the scientific knowledge about the virus including the transmission of the disease
and the measures available to curbthe spread of the disease. A multi-pronged
approach has been taken to fight the COVID-19 infection Malaysia has
implemented 3 phases of outbreak control, which are containment, mitigation and
suppression (Vivek, Sanjay, Chiu & Diane, 2021). Contact tracing, isolation,
testing, restriction of movement, and public health awareness are the measures
that have been taken by government in order to reduce the spread of the disease.
As of 5 March 2022, Malaysia reported 3,561, 766 confirmed COVID-19 cases,
39,936 deaths including brought in dead and 3,223 650 (Ministry of Health) cases
have recovered. Malaysia has been hit by four waves of COVID-19 which
contributed by travelling history to affected countries, large gathering, non-
compliance to SOP, leading to formation of local clusters of cases. Different types
of clusters have been identified in Malaysia including community cluster, funeral,
workplace, institutional, detention center, wedding and also nursing home cluster.
Malaysia has reported a total of 6826 clusters as of 5 March 2022 with various
categories.
Kedah State of Malaysia has recorded a cumulative of 244,050 cases as of 4
March 2022 with a total death of 2310cases. A 298 total clusters of COVID-19 are
one of the factors that contributed to the surge in COVID- 19 cases in Kedah.
Being the smallest district of Kedah State in Malaysia, Bandar Baharu district has
reported a cumulative of 5954 cases as of 4 March 2022, with total of 9 clusters
have been recorded. None of these clusters has been explored and evaluated
yet. Pintu Air Relau Cluster, categorized as a community cluster, is the largest
COVID-19 cluster discovered in subdistrict of Bandar Baharu, namely Relau.
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Thus, this study aims to explore the characteristic of COVID-19 cases and the
approach taken to curb the outbreak that could immensely enhance the healthcare
team for a better preparedness during global health crisis in the future.
METHODOLOGY
Setting, participants, instruments
This descriptive study was conducted among 251 positive cases of Pintu Air
Relau Cluster from 25 April 2021 to 13 May 2021. All the positive cases
irrespective of age, gender and ethnicity, were included as the study
population. Data were collected during case investigation using a structure
investigation case format.
Measurements
Sociodemographic characteristics : The information collected from this section
includes age, gender, ethnicity, occupations, manifestation of disease,
comorbidity and residency.
Approach taken to curb the spread of the massive COVID-19 outbreak : The
details assembled from this section includes the measures and efforts taken
during controlling the cluster of COVID-19 by all the interprofessional teams in
Bandar Baharu District.
Statistical analysis
Data received from the respondents was automatically organized in Microsoft
Excel. The data were then imported to SPSS worksheet. An exploratory data
analysis was done to determine any inconsistent or missing data. Upon
validation, a descriptive analysis was done and presented with frequency tables.
The analysis was done via IBM SPSS version 26.0 (IBM SPSS, 2019)
RESULTS
The data were collected from all the positive cases of Pintu Air Relau Clusters
from 25 April 2021 to13 May 2021. A total of 251 data were analyzed.
Sociodemographic characteristics of the respondents
The mean age of the respondent was 45.34 with standard deviation of 20.387
years. Male predominate the respondent with 51.8%, while female is 48.2%. All of
the respondents are Malay (100%). About 65.7% of the respondent have
manifested symptoms, the remaining 34.4% are asymptomatic. Most of the
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respondent are the residence of the area which take up 87.3%, 12.7% are non-
residence. Among all the responders, 72.1% do not have medical comorbidity,
while those who have medical comorbid are about 27.9%. Most of the respondents
are either not working or being a housewife (50.6%), followed by those who are
working (37.8%) and the remaining are students (11.6%). (Table 1)
Approach taken to contain the massive outbreak
The index case responsible for propagation of Pintu Air Relau Cluster is a
67 years old lady with underlying medical comorbid of diabetic mellitus and
hypertension, identified through a symptomatic screening when she did a rt-PCR
test on 23 April 2021 after manifested symptoms of fever, cough, headache and
myalgia on 13 April 2021 and the results turned out to be positive of COVID-19 on
25 April 2021. Two weeks prior to developing the symptoms, the index case was
diligently involved in religious activities like teaching and reciting Quran in group
and perform prayer in group at the mosque. The activities were continued for two
days after she developed symptoms and it stopped after that due to unwell
condition.
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Table 1 Sociodemographic characteristics of the respondents (N=251)
Characteristics N Percentage
Age
1-10 10 4.0
11-20 25 10.0
21-30 42 16.7
31-40 23 9.2
41-50 17 6.8
51-60 61 24.3
61-70 63 25.1
71-80 6 2.4
81-90 4 1.6
Gender
Male 130 51.8
Female 121 48.2
Ethnicity
Malay 250 100
Symptomatic
Yes 165 65.7
No 86 34.3
Residency
Resident 219 87.3
Non-resident 32 12.7
Comorbid
Yes 70 27.9
No 181 72.1
Occupation
Not Working 127 50.6
Working 95 37.8
Student 29 11.6
After verification of the outbreak by Rapid Assessment Team, operation room was
set up to investigate the outbreak. Early detection of the outbreak has been done
by identifying the close contacts. A total of 1137 contacts of the index case has
been identified, isolated and tested for those who manifested symptoms only. When
the contacts are identified, about 30 people turned out be tested positive COVID-
19, the day after the index case was diagnosed with COVID-19. Bandar Baharu
District Health Office declared the largest cluster in the district on 28 April 2021 and
it was named as Pintu Air Relau Cluster. The enforcement team has issued Home
surveillance order to all the positive cases and close contacts and all of them were
quarantined.
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Enhanced active case detection for COVID-19 has been conducted in Relau to
minimize the risk of widespread transmission in the community. Movement
restrictions has been implemented in Relau in response to the COVID-19 outbreak.
Unfortunately, due to high transmission of disease, we detected 5 generations of
COVID-19 cases for this cluster. The last case was detected on 14 May 2021, and
the cluster ended on 28 May 2021. Figure 1 shows Epid Curve of Pinru Air Relau
Cluster.
Figue 1: Epid Curve of Pinru Air Relau Cluster
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DISCUSSION
A thorough case investigation was done for this case and the source of infection
concluded tobe from a community spread. The name was given according to the
place of origin of the index case. The significant factor that contributed to the rapid
evolution of the COVID-19 cases which lead to the formation of the largest clusters
is religious gathering. As the index case was actively involved with religious activities
with the residents in Relau, it has cause havoc acrossthe suburb area. The religious
activities that have been identified are reciting Quran in a group, praying in group,
and attending multiple religious events.The compliance of SOP against COVID-19
is the major concern during these activities as it is unpredictable. The most affected
age group in this cluster are 51 years old and above. Since this is a rural area,
people around this age are mostly pensioner who live their retirement life at their
place of origin. This could also justify that 50.6% of the respondent are not working
or some of them are being housewife and most of them (87.3%) are residents of
the area might be due to the above-mentioned factor.
Since majority of the residence here are from Malay ethnicity and the transmission of
the disease is contributed by religious gathering, this could explain that all the
respondent (100%) are from Malay ethnicity. Male gender was more affected than
female with a percentage of 51.8% probably due to they are actively moving outside
compared to female. However, 72.1% of the positive cases do not have underlying
medical comorbidities. Poor health seeking behavior could be one of the factors, as
they might not go for the health screening thus make it is less recorded. Bandar Baharu
District Health Office has implemented a holistic and interprofessional approach with a
success and fast coordinated response to contain the spread of the disease particularly
in the domains of alertness about the outbreak, vigorous contact tracing, isolation and
quarantine, epidemiological surveillance for COVID-19 and movement restriction.
When Rapid Assessment Team has identified and verified the outbreak, operation
room has been activated to initiate activities design to investigate, control and contain
the disease. The severity of the outbreak was also evaluated. A multidisciplinary
approach includes the review of the epidemiological data and trend, clinical
examination of cases, review of medical records and review of laboratory results has
been done with unusual thoroughness. Case line listing and the epidemic curve was
updated on daily basis. The field data were collected by Rapid Response Team for
data analysis and interpretation to create an effective strategy and planning to cease
the massive outbreak.
Bandar Baharu District Health Office isolated infected patients and close contacts,
increased compliance by supporting those in quarantine, and traced contacts with
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scrupulous attention to detail. Human resources have been escalated in number and
were deployed for these tracing efforts.
Enforcement team has imposed the mandatory Home Surveillance Order (HSO) to all
the positive cases and close contacts to undergo a mandatory fourteen-day quarantine
period with a stringent quarantine monitoring and policy. On possible actions on an
offender, maximum RM1,000 compound could be issued according to Act 342 (the
Prevention and Control of Infectious Diseases Act 1988).
Extensive epidemiological surveillance for COVID-19 conducted in Relau has utilized
its maximum amount in human resources in Bandar Baharu District Health Office from
various department to cope with this extraordinary crisis. About a quarter of healthcare
workers in Bandar Baharu District Health Office including doctors, nurses, assistant
medical officers, medical laboratory technologist, drivers, health care assistant were
all involved ranging from preparation, collect swab samples for COVID-testing,
packaging, transportation till the interpretation of the results of the COVID-19 testing.
The district health office has maintained approximately 1200 screening with self-testing
center and limited capacity reaching less than 100 per day. All the healthcare team
deployed to the high-density transmission area and experienced transportation
barriers as the healthcare team used their own transport as the limited district health
office transportation unable to cater the large amount of number of the healthcare
team.
To reverse the devastating effects of the pandemic, the measures has been intensified
with the strict movement control in that area. The community is not allowed to leave
the house if there is no need for an emergency. Movements of the community in Relau
subdistrict was also controlled by Royal Malaysian Police (PDRM). The collaboration
from various interprofessional team including the Bandar Baharu District Health Office,
Royal Malaysian Police (PDRM), and local authorities has enhanced the measures to
interrupt the chains of transmission of SARS-CoV-2. As the highest authority in the
district, Bandar Baharu District Office has coordinated all other agencies to smoothen
the process of controlling the spread of the disease. Royal Malaysian Police (PDRM)
assisting in enforcing travel restrictions and ensuring public compliance with standard
operating procedures (SOP) to break the chain of the Covid-19 infection. Malaysia Civil
Defense Department (APM) aided in issuing the wristbands to the individuals who were
given the home surveillance order. Meanwhile, Malaysia Volunteers Corps
Department (RELA) facilitate in coordination during active case detection was
conducted in Relau.
Even though Pintu Air Relau Cluster is not as extravagant as the infamous Covid-19
'tabligh cluster', the Malaysia’s biggest Covid-19 cluster, (Safuan, S., & Edinur, H. A.,
2020), but it’s massive local transmission within a small suburb area which had caused
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a phenomenal requiring diverse expertise should be accentuated. Pesanteran Cluster,
one of the top 5 clusters in Malaysia, a similar cluster linked to religious gathering, with
a total of 238 positive cases were identified, initially reported on 16 April 2020 and
ended on 20 June 2020 (Danial, Monica et al.,2020), showing that the transmission of
the cluster sustained for about two months of duration. In comparison to Pesanteran
Cluster, it is worth noting that Bandar Baharu District Health Office was able to declare
end of Pintu Air Relau Cluster in a more expeditious manner with no death reported
from this cluster.
There are various limitations and challenges arise during controlling the outbreak
which includes staff and also community factors. The healthcare staff were
compromised in terms of safety when being deployed to the area and the limited
human resources for the surveillance screening, including the swab capacity and
equipment and monitoring the contacts under Home Surveillance Oder (HSO). Others
factors that need to be considered during the active case detection (ACD) are the
transportation, the cost, and the climate. To combat the massive outbreak in the amidst
of holy fasting month of Ramadhan, it took a mental and physical toll on people to be
even more demanding to be active but through unity, the healthcare staff were able to
endure the difficulty. It is a quite a challenging while giving public health awareness to
the community, where the health care staff needs to convince the community to
undergo the COVID- 19 test even though they are asymptomatic because all
individuals are at risk of contracting this infection.
In addition, health education plays a critical role in this measure as the community
needs to understand the importance to be tested for COVID-19 as they are living in a
high risk exposure area and they must be strongly educated to adhere to the Home
Surveillance Oder (HSO) as one of the SOP against COVID-19. To enhance the
measures taken to reduce the spread of the disease, healthcare infrastructure and
individual-level knowledge and compliance critically need to be upgraded. There are
several limitations while conducting this study. Firstly, there are several important
epidemiology indicators that cannot be obtained. The input of surveillance might be
further explored by including data on admission facilities, category of COVID-19 cases,
type of exposures and vaccination status to increase the sensitivity of the surveillance
network. In addition, the publication of this study may be reported in different formats,
but it cannot be distinguished with the urban population or other rural areas in Malaysia
as the targeted population was among the rural community and also due to different
demographic patterns in the current study.
CONCLUSIONS
The exponential increase of the cases was proved to be due to religious and social
congregations and were the rocket fuel for the rapid transmission and dispersal hubs
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of the pathogens. It is key at this juncture to reflect that excellent coordination of
participatory action, fast and vigorous responses, appropriate strategy, and good
collaboration played the crucial role to drive changes in the epidemic curve of the
massive outbreak in a speedy period and give positive results to both individual and
society.
ACKNOWLEDGEMENTS
The authors would like to thank the Director General of Health Malaysia for his
permission to publish this paper. We expressed our gratitude for the support from
Bandar Baharu District Health Office for conducting the study. We gratefully
acknowledge the encouragement and assist of Bandar Baharu District Health
Officer. We would like to extend our appreciation to all the responders in the Pintu
Air Relau Clustersfor the given cooperation to participate in this study.
REFERENCE
Asita Elngoe (2020). COVID-19 Outbreak in Malysia,Osong Public Health and
Research Perspective.
Franck de Laval, Anais Grosset-Janin, Francois Delon, Alexandre Allonneau,
Chrstelle Tong, Flaview Letois, Anne Couderec, Marc-Antoine Sanchez,
Cesar Destanque, Fabrice Biot, Francoise Raynaudm Christine Bigaillon,
Oliview Ferrris, Etienne Simon-Loriere, Vincent Enouf, Dinaherisoa
Andriamanantena, Vincent Pommier de Santi, Emilie Javelle & Audreu
Merens (2021). Lessons learned from the investigation of a COVID-19 cluster
in Creil, France: effectiveness of targeting symptomatic cases and
conducting contact tracing around them.
Hafizuddin Awang, Effah Leiylena Yaacob, Sharifah Nadira Syed Aluawi,
Muhammad Faris Madmood, Fathul Hakim Hamzah, Azmani Wahab,
Norafidah Abdul Rashid, Rosmaliza Razali, Goh Soo Ning, Kasemani
Embong & Nor Azimi Yunus (2021). case-control study of determinants for
COVID-19 infection based on contact tracing in Dungun district, Terengganu
state of Malaysia.
Hisham Atan Edinur, Sabreena Safuan (2020). Sri Petaling COVID-19 cluster in
Malaysia:challenges and the mitigation strategies.
Hua Zhang, Feng Du, Xiao-jun Cao, Xia-long Feng, He-ping Zhang, Zheng-xia Wu,
Bao-Feng Wang, Hong-juan Zhang, Rui Liu, Jian-jun Ynag, Bo Ning, Kai
Chen and Zhen-peng Huang (2021). Clinical characteristics of coronavirus
disease 2019 (COVID-19) in patients out of Wuhan from China:a case control
study.
19
Jamal Hisham Hashim, Mohammad Adam Adman, Zailina Hashim, Mohd Firdaus
Mohd Radi and Soo Chen Kwan (2021). COVID-19 Epidemic in
Malaysia:Epidemic Porgression, Challenges, and Response.
L Rampal, B S Liew (2021). Malaysia’s third COVID-19 wave- a paradigm shift
required.
Malaysian Journal of Public Health Medicine Volume 21 (Supplement 4) (2021),
Malaysian Public Health Physicians’ Association.
Marco Cascella;Michael Rajnik;Abdul Aleem;Scott C. Dulebohn;Raffaela Di Napoli
(2020). Features, Evaluation, and Treatment of Coronavirus(COVID-19)
Mohd Shaiful Azlan Kassim, Chong Zhuo Lin, Thilaka Chinnayah @ Nadarajah,
Noor Ani Ahmad, Noor Aliza Lodz, Shaharom Nor Azian Che Mat Din, Aman
Rabu, Norasikin Mahdan, Norli Rosli, Mohd Aliff Wahid (2020). First Cluster
of COVID-19 cases in Malaysia: Public Health Responses and Challenges.
Monica Danial, Ann Lisa rulappen, Alan Swee Hock Ch’ng, Irene Looi (2020).
Mitigation of covid-19 clusters in Malaysia.
Noor Ani Ahmad, Chong Zhuo Lin, Sunita Abd Rahman, Muhammad Haikal bin
Ghazali, Ezy Eriyani Nadzari, Zazarida Zakiman, Suziana Redzuan, Salina
Md Taib, Mohd Shaiful Azlan Kassim, Wan Noraini Wan Mohamed Noor
(2020). First Local Transmission Cluster of COVID-19 in Malaysia:Public
Health Response.
Noorfatekah Talib, Nur Nabila Mohd Fuad, Nurhafiza Md Saad, Nurul Ain Mohd Zaki,
Nurhanisah Hashim, Mohd Amsyar Abdullah (2021). Towards A Strategic
Approach of COVID-19 Cluster Web Mapping in Malaysia.
Sonia Umair, Umair Waqas, Muhammad Faheem (2020). COVID-19
pandemic:stringent measures of Malaysia and implications for other
countries.
Tao Liu, Dexin Gong, Jianpeng Xiao, Jianxiong Hu, Guanhao He, Zuhua Rong and
Wenjun Ma (2020). Cluster infections play important roles in the rapid
evolution of COVID-19 transmission: A systematic review.
The Official Malaysia government website for data and insights on COVID-19 (2022),
https://covidnow.moh.gov.my/.
Understanding ‘Clusters’ (2020), https://publichealthmdc.com/blog/understanding-
clusters
Vivek Jason Jayaraj, Sanjay Rampal, Chiu-Wan Ng, Diane Woei Quan Chong
(2021).The Epidemiology of COVID-19 in Malaysia.
Where Are COVID-19 Clusters Found In Malaysia?(2021)
https://codeblue.galencentre.org/2021/04/07/where-are-covid-19-clusters-found-in-
malaysia/
WHO considerations in the investigation of cases and clusters of COVID-19 Interim
guidance (2020). https://www.who.int/publications/i/item/considerations-in-
the- investigation-of-cases-and-clusters-of-covid-19
20
WHO: Malaysia Coronavirus Disease 2019 (COVID-19) Situation Report (Report
6,2020), https://www.who.int/malaysia/emergencies/covid-19-in-
malaysia/situation-reports
Yoo-Jung Choi, Mi-Jeong Park, Soo Jin Park, Dongui Hong, Sohya Lee, Kyung-Shin
Lee, Sungji Moon, Jinwoo Cho, Yoonyoung Jang, Dongwook Lee, Aesun
Shin, Yun-Chul Hong, Jong-Koo Lee (2021). Types of COVID-19 clusters and
their relationship with social distancing in the Seoul metropolitan area, South
Korea.
Zen Yang Ang, Kit Yee Cheah, Md.Sharif Shakirah, Weng Hong Fun, Jailani Anis-
Syakira, Yuke-Lin Kong and Sondi Sararaks (2021). Malaysia’s Health
Systems Response to COVID-19.
21
SEMI-ENHANCED MOVEMENT CONTROL ORDER (SEMCO): AN
APPROACH IN COMBATING PANDEMIC COVID-19 IN TAMAN
DESA BIDARA, KUALA KETIL, BALING, KEDAH
Eriyani E. 1, Hazwanim H 2, Mohd Izzat M.R 3, Nur Syuhaida S.3, Mohd Zamir
M. 1, Azizul H.A 2
1 Pejabat Kesihatan Daerah Baling, Baling, Kedah
2 Klinik Kesihatan Kuala Ketil, Kuala Ketil, Kedah
3 Unit Inspektorat, Pejabat Kesihatan Daerah Baling, Baling, Kedah
*Corresponding author: Dr Ezy Eryani Bt Nadzari, Pejabat Kesihatan Daerah Baling, Baling, Kedah,
[email protected]
_______________________________________________________________________________
ABSTRACT
Background: Semi-Enhanced Movement Control Order (SEMCO) Taman Desa Bidara
Kuala Ketil, Baling was among the movement control order held in order to control the
spread of COVID-19 infection among the community cluster. This study describes the
planning and management of District Health Office (DHO) on implementing SEMCO in
controlling and preventing further spread of infection of COVID-19 at Taman Desa
Bidara, Baling.
Methodology: This cross-sectional study design has sampled 145 residents in Taman
Desa Bidara for COVID-19 during the SEMCO period (31st July 2021 – 27th August
2021). A house to house survey were conducted for data collection used in the study.
All residents who underwent COVID-19 test were included in the study population. Data
were collected by compiling the line listing of symptomatic individuals and close
contacts living under SEMCO Taman Desa Bidara area identified and verified by
COVID-19 operational room District Health Office, Baling. Statistical Package for Social
Science (SPSS) Version 26 was used for data entry and analysis.
Results: Out of 145 samples, 50 confirmed COVID-19 cases were identified. 41 were
Malaysians (80%), 34 individuals from the age 18 to 50 years old (68%) and 40
individuals had not received at least 1 dose of vaccine (80%) while no death was
reported. COVID-19 infection among residents in Taman Desa Bidara mainly involved
those who worked in manufacturing sector which eventually lead to transmission among
communities. The implementation of SEMCO within 2 weeks period was proven to
reduce number of cases by reducing the probability of contact within community.
Conclusion: The decision to implement SEMCO in Taman Desa Bidara as a measure
to contain COVID-19 outbreak was proven to be effective as the number of positive
cases decreased radically and was proven to serve its purpose.
Keyword: SEMCO, COVID-19, industrial, cluster, Pandemic
22
INTRODUCTION
At the end of December 2019, the first Coronavirus disease 2019 (COVID-19) was
detected in the city of Wuhan, China and presented as an outbreak of pneumonia
with unknown etiology (WHO, 2020). The worldwide spread of the disease prompted
World Health Organization (WHO) to declare the outbreak as a global pandemic on
11th of March 2020. During the early phase of the pandemic, many countries started
to implement various public health interventions by introducing physical distancing
even lockdown measures to suppress the transmission of Covid-19.
Malaysia recorded a high number of Covid-19 cases following a religious mass
gathering in Kuala Lumpur which eventually lead to the first-ever set of nationwide
lockdown measures known as Movement Control Order (MCO) on 18th of March
2020. The enforcement of MCO nationwide aimed to curb the spread of COVID-19
in the community. Malaysians were confined to their homes and only allowed to
travel within a 10 km radius from home for essential or emergency reasons during
this period (Tay et al., 2021).
According to Abdul Khaiyom (2021), the order was implemented following the
Prevention and Control of Infectious Disease Act 1988 (Act 342) and the Police Act
1967. The Regulation of Measures within Infected Local Areas 2020, under the Act
342, gave the minister authorities to institute prohibition of activities, control of
movement within and between infected areas and control of gathering and
processions (Ab Rahim et al., 2020). Ab Rahim et al also pointed out that the order
was reviewed on a regular basis and adjustment were made according to the
pandemic progress. Other control measures introduced by government includes
Conditional Movement Control Order (CMCO), Recovery Movement Control Order
(RMCO), Enhanced Movement Control Order (EMCO).
This study highlights the chronology of events contributed to the spread of COVID-
19 in Taman Desa Bidara Kuala Ketil which made up for the decision and the need
for the Semi-Enhanced Movement Control Order (SEMCO). The general objective
of this study is to describe the management flow of SEMCO in Taman Desa Bidara,
Kuala Ketil, Baling Kedah. The specific objectives are to describe the
sociodemographic pattern of population sampled, to describe the vaccination status
of population sample in SEMCO area, to examine and describe the factors
contributing to COVID-19 infection and its association in SEMCO Taman Desa
Bidara. The findings of this case report could further help in improving public health
measures in managing COVID-19 infection in the community.
23
METHODOLOGY
Study design
This was a cross sectional study design. Data used in this study were collected by
Covid-19 Operational Room of Baling District Health Office.
Study population
A total of 145 residents in Taman Desa Bidara who are symptomatic were tested for
COVID-19 during the SEMCO period (31st July 2021 – 27th August 2021).
Exclusion or inclusion criteria
The inclusion criteria for the study are individuals who live within SEMCO area, with
COVID-19 symptoms or a close contact to a positive COVID-19 case, with or without
comorbidity. The exclusion criteria for population sampled include individuals who
live within SEMCO area but did not meet the criteria listed previously. The sampling
flow for residents in Taman Desa Bidara is as shown in Figure 1 below.
Figure 1: Sampling flow for Taman Desa Bidara residents during SEMCO
24
Sample size calculation
This was purposive sampling as all residents who were tested for COVID-19.
Data collection method
Data were collected using line listing of positive and negative patients in SEMCO
Taman Desa Bidara identified and verified by COVID-19 operational room District
Health Office Baling. Data were clean and were categorized according to the case
status. A survey from house to house was also conducted by Baling District Health
Office. Residents in Taman Desa Bidara were asked to fill in their information which
includes the list of members in the same house, their ouccupation status,
comorbidity, if any and their vaccination status.
Outcome measure
i. COVID-19
A resident or person who developed any symptom of COVID-19, such as fever,
cough, flu and sore throat were decided to do COVID-19 test either RT-PCR or RTK-
Ag test. COVID-19 case is defined as an individual with positive COVID-19 results
for both RT-PCR and RTK Ag tests.
ii. Approach on planning and management of implimenting SEMCO
A series of meeting were held by Baling District Health Office following the increase
in number of positive cases among Taman Desa Bidara residents. A town hall
meeting was then held involving the representatives from various agencies to
discuss the current situation in Baling District where the implementation of SEMCO
was proposed which finally led to the decision to implement SEMCO in Taman Desa
Bidara. Among them were District Officer, police department, district council,
National Security Council, Social Welfare office, politician and community leader.
Risk assessment was made to discuss the activities permitted and prohibited during
the SEMCO implementation. Through the discussion, we decided to implement the
targeted screening approach for best use of resources, focusing on the vulnerable
and high-risk groups.
Statistical analysis
Statistical Package for Social Science (SPSS) Version 26 was used for data entry
and analysis. To summarize and explain the independent variable and dependent
variables, descriptive statistics (frequency, percentage and median) was used. As
the dependent variable was categorical data, an appropriate statistical method was
applied for bivariate analysis which was the chi square test. The chi square test was
used to measure the association between two categorical independent and
dependent variables (sociodemographic factors, vaccination and co-morbid factors).
The level of significance (α) was set at 0.05.
25
RESULTS
Table 1 shows COVID-19 status among 145 individuals tested in SEMCO Taman
Desa Bidara. Out of this number, 50 (34.5%) of them turned up to be positive COVID-
19 and 95 (65.5%) of them were negative.
Table 1: Status of COVID-19 among sampling group in Taman Desa Bidara
COVID-19 Status Frequency (n) Percentage (%)
Positive 50 34.5
Negative 95 65.5
Total 145 100
Table 2 shows the characteristics of sampled residents in Taman Desa Bidara. The
age distribution was between 0 to above 71- years old with the majority of them were
among 31 to 50 years old (47%), male (85%), Malaysian (85.5%), Malay ethnicity
(60%).
Table 3 shows the characteristics of positive and negative COVID-19 status among
sampling residents in SEMCO Taman Desa Bidara. Positive COVID-19 cases were
higher among younger age who are 18-50 years old (68%), male (52%), Malaysian
(82%), Malay ethnicity (56%), occupation, Not vaccinated (80%) and no co-morbidity
(88%). However, there were no significant sociodemographic factors, vaccination
status and co-morbid factors between positive COVID-19 and negative COVID-19
status in SEMCO Taman Desa Bidara.
Table 2: Characteristics of sampled residents in Taman Desa Bidara
(N=145)
Characteristic Frequency (n) Percentage (%)
Age (years) 36 24.8
0-17 40 27.6
18-30 47 32.4
31-50 20 13.8
51-70 2 1.4
>70
85 58.6
Gender 60 41.4
Male
Female 124 85.5
21 14.5
Nationality
Malaysian 87 60
Non-Malaysian 5 3.4
31 21.4
Ethnicity
Malay 26
Chinese
Indian
Others 22 15.2
Occupation
9 6.2
Government 9 6.2
Private 50 34.5
Factory 8 5.5
Self employed 69 47.6
None of the above
Vaccination status 116 80
None 5 3.4
Partially vaccinated 24 16.6
Fully vaccinated
Co-morbidities 122 84.1
No 23 15.9
Yes
Table 3: Characteristics of sampled residents in SEMCO Taman Desa Bidara
Characteristic COVID-19 status X2 df P value
Positive,n (%) Negative, n(%)
Age (years)
0-17 9 (18) 27 (29.7) 4.623 4 0.328
18-30 17(34) 23 (25.3)
31-50 17 (34) 27 (29.7)
51-70 7 (14) 12 (13.2)
>70 0 (0) 2 (2.2) 1.379 1 0.240
Gender 26 (52) 59 (62.1)
Male
Female 24 (48) 36 (37.9) 0.762 1 0.383
Nationality 1.854 3 0.603
41(82) 83 (87.4)
Malaysian 9 (18) 12 (13.8) 6.248 4 0.181
Non Malaysian
Ethnicity 28 (56) 59 (62.1) 0.604 2 0.739
Malay 1 (2) 4 (4.2)
Chinese 11 (22) 20 (21.1) 0.853 1 0.356
Indian 10 (20) 12 (12.6)
Others
Occupation 2 (4) 7 (7.4)
Government 1 (2) 8 (8.4)
Private 20 (40) 30 (31.6)
Factory 1 (2) 7 (7.4)
Self employed 26 (52) 43 (45.3)
None of the
above 40 (80) 76 (80)
Vaccination status 1 (2) 4 (4.2)
None
Partially 9 (18) 15 (15.7)
vaccinated
Fully 44 (88) 78 (82.1)
vaccinated 6 (12) 17 (17.9)
Co-morbidities
No
Yes
27
Chronology of events leading to Semi Enhanced Movement Control Order
(SEMCO) in Taman Desa Bidara
On July 5, 2021, a worker from Molnlycke Health Care tested positive for COVID-19
which then led to 125 individuals being traced as close contacts to the positive
COVID-19 case. RT-PCR test was performed and resulted in 31 individuals tested
positive for COVID-19 and the rest were negative. This event led to the declaration
of Dah Ketil Industri Baling Cluster on 14th of July 2021, a cluster involving Molnlycke
Health Care workers. Close contacts to these positive cases were traced and among
them, some live in Taman Desa Bidara. In July 2021 only, a total of 100 cases
involving residents of Taman Desa Bidara had been reported. Among them, 64
positive COVID-19 cases were reported during epid week 28-29 (11th of July 2021
to 24th of July 2021). 39 cases were from Dah Ketil Industri Baling Cluster. A sudden
surge in the number of total positive cases among the residents and Dah Ketil
Industri Baling cluster were the leading factors contributing to SEMCO in Taman
Desa Bidara. Risk assessment was then made and a decision to enforce EMCO in
Taman Desa Bidara was taken.
Following the increase in the number of positive cases among residents of Taman
Desa Bidara, SEMCO was enforced to avoid future outbreaks, and a targeted
sampling was proposed. SEMCO in Taman Desa Bidara was commenced on 31st
July 2021 for two weeks till 13th of August 2021 and then extended for another two
weeks until 27th of August 2021. The targeted sampling focused on those with
COVID-19 symptoms which include fever, cough, shortness of breath, fatigue,
headache, cold, runny nose, vomiting and diarrhoea. During the SEMCO, entry and
exit were not permitted. Residents were not allowed to leave the locality unless they
were given permission by authorized personnel to do so. Announcement was made
by the Baling District Health Office asking residents with symptoms to come over
and undergo RTK-Ag test before proceeding with RT-PCR test if the result turned
out positive. SEMCO was finally lifted on 28th of August 2021.
DISCUSSION
Characteristic of COVID-19 cases in Taman Desa Bidara
During SEMCO implementation, another 50 cases were detected from symptomatic
screening via RT-PCR confirmation test. Majority of the positive cases are less than
the age of 50 years old (68%), Malay ethnicity (56%) and not vaccinated (80%). This
finding was similar with the study of Hassan et al. (2021) and Tian et al. (2020).
28
20 individuals (40%) who tested positive for COVID-19 were factory workers. Other
studies by Mat Din et al. (2021), Wahil et al. (2021) and Fang et al. (2020) had
described that people with comorbidity were at high risk of COVID-19 infection. This
study however found that 44 out of 50 individuals (88%) had no comorbidity. No
death were reported. This is most probably contributed by the number of individuals
without comorbidity were relatively higher than individuals with comorbidity in the
study sample.
Epid Curve in Taman Desa Bidara (1/7 - 27/8/2021)
SEMCO
18 16
16
14
12 11 11
10 99 8 9
8 78 7
8
6 5 5 4
4 4 3
33
4 2 22 11 1
2 111 11 1
0
1-Jul
3-Jul
8-Jul
10-Jul
12-Jul
13-Jul
14-Jul
15-Jul
18-Jul
19-Jul
21-Jul
22-Jul
23-Jul
24-Jul
25-Jul
26-Jul
27-Jul
28-Jul
29-Jul
30-Jul
31-Jul
1-Aug
3-Aug
4-Aug
5-Aug
6-Aug
7-Aug
9-Aug
10-Aug
14-Aug
15-Aug
Jul Aug
Figure 2: Epidemiology curve of positive COVID-19 cases in Taman Desa Bidara
Risk assessment on cases distribution of COVID-19 in Taman Desa Bidara
leading to SEMCO
Starting from July till August 2021, Baling District as other districts in Kedah had
rampant rise of daily cases of COVID-19. Fourteen days movement chart for COVID-
19 case distribution from 14th July until 27th of July showed the number of cases were
highly contributed by Mukim Tawar, Kupang and Pulai. Mukim Tawar contributed the
highest number of cases with 334 cases within 2 weeks duration.
Taman Desa Bidara is located in Mukim Tawar and 5 KM distance from Kuala Ketil
Industrial area. Kuala Ketil Industrial Area It included 1612 houses and 3200
residents. Many factories were running during this period as they were considered
essential services. Some of the factory workers being diagnosed with COVID-19
stayed in Taman Desa Bidara. Total of 218 samples have been taken, 64 samples
were positive and 154 were negative. With a high positive rate of 30%, therefore
29
residents in Taman Desa Bidara are at high risk because majority of the cases are
contributed by factory workers from Dah Industry Ketil Cluster which was still actively
declared. Dah Ketil Industry Baling Cluster contributed the most with 39 cases, close
contact screening (9 cases), symptomatic individuals screening (8 cases) while
Schaefer Kalk and Ryco factory’s screening contributed to 5 and 4 cases
respectively.
From investigation of the cases, COVID-19 spread sporadically in Taman Desa
Bidara. The index case was from a community which spread to the working
environment in factories and finally spread to other family members. It involved 26
houses and at least 2-4 family members being infected with COVID-19. The cases
were not localized in certain locations in the residency area but the positive cases
scattered within Taman Desa Bidara, shown with yellow colour on the residential
area’s plan (Figure 3). This indicated that there was high transmission in this area.
Therefore, lockdown was essential as it is able to contain the infection and control
the public health threat in the community of COVID-19 transmission (Hassan et al.,
2021).
Positive case
Figure 3: COVID-19 distribution in Taman Desa Bidara
30
Organisation, coordination and response
During the pandemic of COVID-19, Baling District Health Office is the representative
of the Ministry of Health (MOH) to give the technical input regarding the situation of
COVID-19 at district level to the District Disaster Management Committee (JBPD)
which is chaired by the District Officer. The information of the data has been shared
on a daily basis with the committee to enhance the decision making regarding the
current situation of the COVID-19 at district level (Ab Rahim et al., 2020).
Before lockdown was announced, a meeting was held at Baling District Office on
28th July 2021, chaired by the District Officer as the Chief Commander, and involving
multiple agencies, including the police department, district council, National Security
Council, Social Welfare office, politician and community leader. The meeting was
intended for coordinating the necessary plan to ensure well-planned action between
agencies.
District health office presented the situational analysis of COVID-19 in Taman Desa
Bidara to the committee and proposed to do enhanced control movement order
(EMCO) to contain the infection aggressively in this area. However, after further
discussion in the meeting, with consideration of the limited ability of the agencies to
supply the food and other necessities to the large area in Taman Desa Bidara, the
committee had decided to implement SEMCO at Taman Desa Bidara. Unlike EMCO,
in the SEMCO area the economic sector was allowed to operate within the cordoned
area and residents were permitted to leave and enter through limited checkpoints
which were tightly controlled by the police. The main agency involved in SEMCO
implementation were district office as a command center, police department to guard
the area, social welfare department to provide food to residents with COVID-19 who
being quarantined and district health office to operate the medical base (Ab Rahim
et al., 2020).
Activities and mobilization of health care worker in SEMCO area
Since 12th May 2021, Malaysia has been under MCO and implementing Phase 1 of
the National Recovery Plan since 16 June. However, the trends in reported cases,
severe cases, deaths and test positivity rates continue to increase. In July 2021,
there were high proportions of reported cases categorized as “sporadic” and
“unlinked at the time of reporting” indicating widespread community transmission.
Other than that, SARS-CoV-2 variants of concern continue to be detected among
local cases, predominantly the beta and delta strains (WHO,2021). Same scenario
31
happened in Kedah as well as in Baling District. In July 2021 Baling District had
reported 1838 COVID-19 cases as compared to 246 cases only in June 2021. Daily
routines for COVID-19 management were investigation of positive cases to identify
the close contact, sampling of suspected cases, home surveillance order for positive
cases and close contacts, home surveillance release order for the person who
already completed the quarantine period and assessment of positive cases at
COVID assessment center (CAC).
The sudden surge of cases and daily routine management in order to control and
contain the COVID-19 cases had overwhelmed the health services in Baling and
impacted health care worker mobilization. Other districts in Kedah were facing the
same burden of managing the COVID-19 cases at that period of time. Therefore,
after considering all these difficulties faced by all districts in Kedah, there was no
mobilization of the health care workers from other districts and no massive sampling
will be conducted during SEMCO in Taman Desa Bidara. The sampling only targeted
the symptomatic individuals who presented at the sampling area inside the SEMCO
area. Total number of samples taken were 230.
The healthcare workers who stayed at SEMCO area were mobilized to the sampling
area,static medical clinic and vaccination station. The sampling area, static clinic and
vaccination station were set up at a mosque compound in Taman Desa Bidara. The
collaboration between government agencies, politicians and community leaders in
the SEMCO area was very good. They played a role to ensure the welfare of the
residents were taken care of and all requirements such as equipment to set up
sampling area, static clinic and vaccination station were provided as soon as
possible after the SEMCO was announced by Malaysian Senior Security Minister
28th of July 2021. Patients who confirmed positive RT-PCR were brought to COVID
assessment center (CAC) 10km away from the SEMCO area. Patients were
transported by designated transportation as there was barely sufficient manpower of
health care workers to run the CAC inside the SEMCO. In that period, residents in
Taman Desa Bidara were highly cooperative and complied to the rules set by
authorities.
Initially JPBD decided to implement the SEMCO for 2 weeks which was until 13th
July 2021 only. However, there were still ongoing new cases detected and many of
the positive cases and close contacts were quarantined at home. Considering
ongoing active transmission inside the SEMCO region, The SEMCO had been
extended to another two weeks until 27th of July 2021. The last case being reported
was on 15th of July 2021, 12 days before the SEMCO was lifted. Slow containment
32
of the positive cases might be contributed by the targeted screening only among
symptomatic patients and no massive sampling has been done. As mentioned by
another study, those contracted by COVID-19 majority are asymptomatic (Hassan
et al., 2021). Study by Romagnani et al. (2020) found that testing both symptomatic
and asymptomatic cases is more effective strategy to mitigate the epidemic impact.
Vaccination is another main public health measures strategy to control further
transmission COVID-19 in the community. COVID-19 vaccine had proven to protect
the person from being infected by COVID-19 and decline the death rate of COVID-
19 in population (Taib et al., 2021 & Rosenberg et al., 2022). Malaysia's National
COVID-19 Immunization Programme began at the end of February 2021. The
programme had rolled out in three phases. The programme aimed to vaccinate over
80% of the population. The first phase was carried out starting from February 2021
and aims to vaccinate 500 000 health-care workers and front-line workers. The
second phase commenced in May 2021 and immunized about 9.4 million individuals
in high-risk groups. High-risk groups included senior citizens aged 60 years and
older and vulnerable groups who suffer chronic underlying diseases. The third phase
covered the general public except children starting in August 2021 (WHO, 2021).
Same strategy was implemented in SEMCO Taman Desa Bidara. Rapid
assessment team had mobilized to the SEMCO area to do surveys from house to
house to get the information on vaccination status of all residents in the SEMCO
area. From the survey, only 10% of the population had completed 2 doses of
COVID-19 vaccine. The need of achieving ring immunity was crucial in order to
prevent further infection in this high-risk area. The vaccination station has been set
up in the SEMCO Taman Desa Bidara. The health promotion unit had made an
announcement to the community to get their vaccination at the mosque compound.
The information was also being shared via community leaders in the SEMCO area.
Apart from that, residents in SEMCO area received push notification through
MySejahtera application where the vaccinee will be notified with the details of their
vaccination appointment. Majority of the residents had not yet received a single dose
of vaccine during this period as the National COVID-19 Immunization Programme
were still at the early phase. They had not yet received the date of appointment for
their first dose although registration had been made through MySejahtera
application. 116 individuals who took part in the targeted sampling were not
vaccinated during the commencement of SEMCO. Residents who have received at
least a single dose of vaccine at the time mostly were healthcare workers or those
who worked in critical manufacturing sub-sectors and listed in Program Imunisasi
Industri COVID-19 Kerjasama Awam-Swasta (PIKAS).
33
CONCLUSION
COVID-19 pandemic has affected the lives of many in so many ways be it having to
take extra precautions on hygiene practice, losing source of income due to economic
growth disruption and worse, losing family members or close acquaintances as a
result of this disease. The Malaysian government has decided to enact a Movement
Control Order (MCO) to handle this situation due to the nature of the virus, which is
highly contagious. In Taman Desa Bidara too, the same decision was made and
SEMCO has been enforced. The decision to implement SEMCO in Taman Desa
Bidara as a measure to contain COVID-19 outbreak was proven to be effective as
the number of positive cases decreased radically. Good cooperation from residents
in complying with the rules set by authorities and inter-agency cooperation are
essential and definitely contributed a lot in combating this pandemic.
REFERENCES
Ab Rahim, I., Amer Nordin, A., Tan, E. H., & Ahmad Shauki, N. I. (2020). Universal
Health Coverage and COVID-19 Preparedness & Response in Malaysia. In
www.who.int. https://www.who.int/malaysia/news/detail/04-09-2020-
universal-health-coverage-and-covid-19-preparedness-response-in-
malaysia
Abdul Khaiyom, J. H. (2020). Managing Mental Health in Pandemic COVID-19 and
Movement Control Order. Malaysian Journal of Medical Sciences, 27(4),
147–153. https://doi.org/10.21315/mjms2020.27.4.14
Fang, L., Karakiulakis, G., & Roth, M. (2020). Are patients with hypertension and
diabetes mellitus at increased risk for COVID-19 infection? The Lancet
Respiratory Medicine, 8(4). https://doi.org/10.1016/s2213-2600(20)30116-8
Hassan, M. R., Subahir, M. N., Rosli, L., Che Mat Din, S. N. A., Ismail, N. Z., Bahuri,
N. H. A., Ibrahim, F., Othman, N., Abas, Z., & Mohammed Nawi, A. (2021).
Malaysian Enhanced Movement Control Order (EMCO): a unique and
impactful approach to combating pandemic COVID-19. Journal of Health
Research, ahead-of-print(ahead-of-print). https://doi.org/10.1108/jhr-01-
2021-0037
Mat Din, H., Raja Adnan, R. N. E., Nor Akahbar, S. A., & Ahmad, S. A. (2021).
Characteristics of COVID-19-Related Deaths Among Older Adults in
Malaysia. The Malaysian Journal of Medical Sciences : MJMS, 28(4), 138–
145. https://doi.org/10.21315/mjms2021.28.4.14
Romagnani, P., Gnone, G., Guzzi, F., Negrini, S., Guastalla, A., Annunziato, F.,
Romagnani, S., & De Palma, R. (2020). The COVID-19 infection: lessons
from the Italian experience. Journal of Public Health Policy, 41(3), 238–244.
https://doi.org/10.1057/s41271-020-00229-y
34
Rosenberg, E. S., Dorabawila, V., Easton, D., Bauer, U. E., Kumar, J., Hoen, R.,
Hoefer, D., Wu, M., Lutterloh, E., Conroy, M. B., Greene, D., & Zucker, H. A.
(2021). Covid-19 Vaccine Effectiveness in New York State. New England
Journal of Medicine, 386(116-127). https://doi.org/10.1056/nejmoa2116063
Taib, N. A. A., Raja, D. B., Teo, A. K. J., Kamarulzaman, A., William, T., Hs, A.-S.,
Mokhtar, S. A., Ting, C.-Y., Yap, W. A., Kim, M. C. Y., & Amir, L. E. (2022).
Characterisation of COVID-19 deaths by vaccination types and status in
Malaysia between February and September 2021. The Lancet Regional
Health – Western Pacific, 18. https://doi.org/10.1016/j.lanwpc.2021.100354
Tay, Y. L., Abdullah, Z., Chelladorai, K., Low, L. L., & Tong, S. F. (2021). Perception
of the Movement Control Order during the COVID-19 Pandemic: A Qualitative
Study in Malaysia. International Journal of Environmental Research and
Public Health, 18(16), 8778. https://doi.org/10.3390/ijerph18168778
Tian, S., Hu, N., Lou, J., Chen, K., Kang, X., Xiang, Z., Chen, H., Wang, D., Liu, N.,
Liu, D., Chen, G., Zhang, Y., Li, D., Li, J., Lian, H., Niu, S., Zhang, L., & Zhang,
J. (2020). Characteristics of COVID-19 infection in Beijing. Journal of
Infection, 80(4), 401–406. https://doi.org/10.1016/j.jinf.2020.02.018
Wahil, M. S. A., Jaafar, M. H., Ismail, R., Chua, S. P., Jeevananthan, C., Sandhu, R.
S., Madrim, M. F., & Haddi, A. A. A. (2021). Preliminary Study on Associated
Risk Factors of Mortality Due to COVID-19 Pandemic in Malaysia. Medical
Sciences Forum, 4(1), 8. https://doi.org/10.3390/ECERPH-3-09022
World Health Organization (WHO). (2020). Pneumonia of Unknown Cause - China.
Retrieved on 15 January 2022 from
https://www.who.int/emergencies/disease-outbreak-news/item/2020-
DON229
World Health Organization (WHO). (2021). Malaysia, Coronavirus Disease 2019
(COVID-19) Situation Report, Weekly report for the week ending 7 February
2021. Retrieved on 22 January 2022 from https://www.who.int/malaysia/
World Health Organization (WHO). (2021). Malaysia, Coronavirus Disease 2019
(COVID-19) Situation Report, Weekly report for the week ending 18 July
2021. Retrieved on 15 January 2022 from https://www.who.int/malaysia/
35
RISK FACTORS OF SEVERE CLINICAL OUTCOME COVID-19
CASES IN KULIM, KEDAH BETWEEN AUGUST AND DECEMBER
2021
Farah Fatin F.1*, Elliza M1,2, Muhammad Suhail A.W1, Cik Normadiah S1,
Alias A.Z1
1Kulim District Health Office, Kedah Health Department
2Universiti Putra Malaysia
*Corresponding author: Farah Fatin Fauzi, [email protected]
ABSTRACT
Background: As of December 26, 2021, Malaysia had more than 2.7 million COVID-19
cases, with more than 166 thousand cases, or 6.1% were reported in Kedah. Additionally,
over 21% of them are from Kulim District, which makes this district among those with a high
number of COVID-19 in Kedah. This study aimed to determine the risk factor of severe
clinical outcome COVID-19 cases in Kulim, Kedah.
Methodology: This was a cross-sectional study utilising COVID-19 data gathered from
routine daily district surveillance and collected by the Kulim COVID-19 Assessment Centre
(CAC) between 1st August 2021 and 15th December 2021. From all 27649 subject data in
the sampling frame, the final analysis included those that met the selection criteria using a
simple random sampling method with a final sample size of 2269.
Results: From the final model of multiple logistic regression analysis, severe clinical
outcome was found to be 56 times higher in those age 60 years and more (aOR, 56.4; 95%
CI, 12.61-252.38) followed by those in age group of 46 to 59 years old (aOR, 7.31; 95% CI,
1.59-33.62). Unvaccinated COVID-19 patients were found to be 2.7 times more at risk of
having severe clinical outcome (aOR, 2.7; 95% CI, 1.56-4.69) as compared to fully
vaccinated with two doses of COVID-19 vaccine cases. Having symptoms upon diagnosis
of COVID-19 was also strongly a risk factors in developing severe clinical outcome as
compared to those with asymptomatic cases (aOR, 10.03; 95% CI, 4.34-23.20).
Conclusion: Age 60 years and more, unvaccinated and symptomatic upon first diagnosis
are among the risk factors contributed towards severe clinical outcome of COVID-19. Thus,
protecting the elderly, completed vaccination of COVID-19, and early screening should be
emphasized in managing COVID-19 to prevent severe clinical outcome.
Keyword: COVID-19, risk factor, characterisation, Kulim, Kedah
36
INTRODUCTION
COVID-19 has rapidly spread to become a global pandemic nowadays. Since the
first case reported in January 2022, Malaysia had more than 2.7 million COVID-19
cases as of December 26, 2021, with more than 166 thousand cases, or 6.1% were
reported in Kedah (Hashim et al., 2021; Ministry of Health (MOH) Malaysia, 2021).
Additionally, over 21% of them are from Kulim District, which makes this district
among those with a high number of COVID-19 in Kedah (Kulim District Office, 2021;
MOH Malaysia, 2021).
One of the government’s initiatives to combat this pandemic is implementing and
accelerating vaccination programs, with 78.3% of Malaysia’s total population
currently vaccinated (MOH Malaysia, 2021, 2021). While the COVID-19 vaccination
may aid in the prevention of serious outcomes, including the risk of mortality, history
has shown that no vaccine is 100% effective (Centers for Disease Control and
Prevention (CDC), 2021; Tenforde et al., 2021). Therefore, there could be a good
effort to study and present an overall view of the characteristic of COVID-19 cases
reported in the community when the Malaysia vaccination program was fully
established.
Few systematic reviews and meta-analyses have reported several risk factors for
COVID-19 critical and serious outcomes, such as age, comorbidity like hypertension
and obesity, presence of certain clinical manifestations, and specific clinic laboratory
findings (Booth et al., 2021; Zhang et al., 2020; Zheng et al., 2020). Furthermore,
recent studies have revealed that vaccination status is a risk factor for adverse
outcomes among COVID-19 patients and the co-existence of other risk factors could
further worsen the consequence for those who have already been vaccinated
(Antonelli et al., 2022; Yek et al., 2022). Although evidences on risk factors of
COVID-19 are yet accumulating, but most studies conducted in China, and focus on
the disease progression in terms of ICU admission and death (Du et al., 2021; Zhang
et al., 2020). Hence, demonstrating the need to perform a study in our local
population and gather factors for severe outcomes defined using clinical staging that
had been practised in our setting.
Globally, there is a demand to systematically strengthen public health activities to
characterise COVID-19 epidemiology in each country (Lipsitch et al., 2020).
However, in Malaysia, published study concerning the epidemiology of the pandemic
is still scarce (Jayaraj et al., 2021). Moreover, no such study, specifically including
the Kulim District population, has been conducted or published to date. Thus, this
study aimed to examine the risk factors for severe clinical outcomes in COVID-19
37
cases in Kulim, Kedah and to better understand and develop prevention strategies,
especially for our community.
METHODOLOGY
Study Design and Data
This was a cross-sectional study utilising COVID-19 data gathered from routine daily
district surveillance and collected by the Kulim COVID-19 assessment centre (CAC)
between 1st August 2021 and 15th December 2021. This study included confirmed
COVID-19 cases registered in Kulim District but excluded subjects with uncertain
vaccination status, those who had been re-infected, and those who were pregnant.
The sample size was determined using OpenEpi, an open-access Web-based
Epidemiologic and Statistical Calculator for Public Health (Dean et al., 2013). Based
on the proportion of male and female COVID-19 cases from a local study (Awang et
al., 2020), with a 95% confidence level and 80% power, a sample size of 2269 was
determined. From all 27649 subject data in the sampling frame, the final analysis
included those that met the selection criteria using a simple random sampling
method.
Operational Definition
The clinical outcome of the COVID-19 case in the form of the disease severity and
death is the primary outcome measure in this study. The severity of the disease is
classified based on COVID-19 clinical staging assessed by CAC, with mild cases
being stage I-III and severe cases being stage IV-V (Sim et al., 2020). The clinical
staging definitions are as follows: stage I: asymptomatic, stage II: symptomatic
without pneumonia, stage III: pneumonia without hypoxia, stage IV: pneumonia with
hypoxia requiring oxygen supplemental therapy, and stage V: severely ill.
Meanwhile, death is defined as ‘yes’ or ‘no’ during the analysis. The COVID-19 case
definition has been evolved with time after many research and studies being done
on how the disease transmitted, the incubation period, method of testing of the
disease and others. Therefore, in this study, confirmed COVID-19 cases were
defined the same as published by Ministry of Health Malaysia in the COVID-19
guideline (ANNEX 1) that have been released serially at that time of point of data
collection were made.
The independent variables in this study comprise sociodemographic characteristics
(age, gender, nationality, race, occupation, and locality), vaccination status,
symptomatic presentation, co-existence of health problems, and type of screening.
Age was defined in years at recruitment based on the date of birth whereby gender
38
is defined as male and female. Nationality was differentiated into Malaysian and
Non-Malaysian. Race was further categorised into Malay, Chinese, Indian, others
Malaysian, and others Non-Malaysian according to major ethnicities in Malaysia.
Occupation was classified and recoded into employed and unemployed. Locality
was divided into fifteen groups based on the number of Mukim in the Kulim district.
Vaccination status was categorised as ‘Yes’ for individuals who received two doses
of vaccination and ‘No’ for those who did not receive any dosage or received only
one dose. Symptomatic presentations were coded as 'Yes' or 'No' based on whether
the individual complained of any symptoms during the CAC assessment. For the co-
existence For the co-existence health problem, we retrieved data on risk factors
measured by the CAC and classified individuals as 'Yes' or 'No' for having
hypertension, diabetes mellitus, being obese/overweight, or having other risk
factors. Other risk factors included health problems like dyslipidaemia, heart
problems, bronchial asthma and any chronic conditions. Meanwhile, types of
screening were categorised into symptomatic screening, close contact screening,
workplace screening and other screening.
Statistical Analysis
Data entry and analysis were performed using IBM SPSS Statistics version 26.0
(IBM Corp). Prior to the analysis, data cleaning was done. Normality testing was
performed on continuous data using Skewness, Kurtosis and histogram. Following
that, descriptive analysis was done performed for all the variables. Categorical data
were described in frequency (n) and percentage (%), whereas continuous data were
shown in mean and standard deviations (SD) or median and interquartile range
(IQR) depending on normality test results.
In the next step, bivariable analysis was done performed using simple logistic
regression to determine the association between outcomes and all the independent
variables. Based on the findings from simple logistic regression, any variables with
a P value of less than 0.25 were included in the subsequent multiple logistic
regression analysis to identify the determinant of the clinical outcome of the COVID-
19 case. Multivariate logistic regressions were performed in a step-wise approach
with results from the final model reported in this study. The results of crude OR
represent for severe COVID-19 disease. Final results were presented as adjusted
odds ratios (aOR’s) with 95% confidence intervals (CI), and the level of significance
was set at P < 0.05.
39
RESULTS
Sociodemographic characteristics of COVID-19 cases upon diagnosis
From 2269 positive cases that have been included after random sampling, the
majority of those in age group of 19 to 45 years old were having only mild disease
severity (61%) as compared to those in the age group of more than 60 years old,
45.1% of them had severe clinical outcome (category 4 and above) with overall age
of more than 45 years old were significantly associated with severe clinical outcome.
By gender, both male and female had nearly equal distribution of severe disease
outcome while male (55.3%, n=1193) presenting with mild form of clinical outcome
slightly higher than female.
The proportion of Malay ethnicity had the most numbers and percentages in both
mild and severe categories with 68.8% (n=1483) and 70.8% (n=80) respectively. The
highest numbers of cases were from mukim Kulim with both mild (22.7%, n=489)
and severe (19.5%, n=22) cases were reported. Mukim Sungai Seluang however in
the other hand noted to have almost similar percentage (18.6%, n=21) of severe
disease as compared to mukim Kulim evenhough it mild (10.4%, n=224) cases were
reported half of mukim Kulim cases. Malaysian citizens contributed more than 90%
for each categories of clinical outcome. In terms of employment, unemployed was
significantly associated with severe clinical outcome (Table 1).
Table 1: Sociodemographic of COVID-19 cases upon diagnosis
Clinical Outcome Crude (95% CI OR)
n (%)
Variables OR X2 df p-
Mild Severe valuea
Age group (Severe)
13-18 years 135.966 3 <
19-45 years 0.001
46-59 years
340 (15.8) 2 (1.8) 1.00 (1.047;18.32) 4.091 1 0.043
60 years 1320 (61.2) 34 (30.1) 4.38 (3.09; 55.69) 12.169
337 (15.6) 26 (23.0) 13.12 1 <0.001
Gender (13.11; 30.236
Male 54.53 226.79) 1.034 b
Female
Ethnic 159 (7.4) 51 (45.1) 1.00 1 <0.001
Malay 1.22
Chinese b
1.00
1.66 1 0.309
1193 (55.3) 57 (50.4) (0.83; 1.78) 1.034 1 0.309
963 (44.7) 56 (49.6) 8.512 4 0.075
1483 (68.8) 80 (70.8)
190 (8.8) 17 (15.0) (0.96;2.86) 3.314 1 0.069
40
Indian 274 (12.7) 8 (7.1) 0.54 (0.26;1.13) 2.657 1 0.103
0 (0) 0.00 -
Others 7 (0.3) 0.00 1 0.999
Malaysian 8 (7.1) 0.73 (0.35;1.54)
0.667 1 0.414
Others Non- 202 (9.4) 3 (2.7) 1.00 (0.10;2.47)
Malaysia 3 (2.7) 0.48 (0.67;15.35) 16.393 14 0.290
4 (3.5) 3.20 (0.54;6.50)
Mukim 21 (18.6) 1.88 (0.30;4.11) 0.762 1 0.383
11 (9.7) 1.11 (0.13;4.98) 2.114 1 0.146
Bagan Sena 60 (2.8) 2 (1.8) 0.80 (0.39;10.89) 0.983 1 0.322
3 (2.7) 2.07 (0.40;7.68) 0.025 1 0.875
Padang Meha 124 (5.8) 5 (4.4) 1.75 (0.13;3.30) 0.057 1 0.811
3 (2.7) 0.65 (0.29;3.91) 0.736 1 0.391
Sedim 25 (1.2) 11 (9.7) 1.06 (0.26;3.10) 0.557 1 0.456
22 (19.5) 0.90 (0.18;2.98) 0.277 1 0.599
Sungai Seluang 224 (10.4) 6 (5.3) 0.72 (0.08;7.75) 0.007 1 0.933
1 (0.9) 0.77 (0.26;3.73) 0.028 1 0.867
Sidam kanan 198 (9.2) 9 (8.0) 0.98 (0.21;3.08) 0.201 1 0.654
9 (8.0) 0.81 0.050 1 0.824
Sungai Ular 50 (2.3) (0.35;1.53) 0.001 1 0.974
105 (92.9) 1.00 0.099 1 0.754
Terap 29 (1.3) 8 7.1) 0.733 0.748 1 0.387
Junjong 57 (2.6) 0.689 1 0.406
Karangan 93 (4.3)
Keladi 208 (9.6)
Kulim 489 (22.7)
Lunas 166 (7.7)
Mahang 26 (1.2)
Naga Lilit 184 (8.5)
Padang Cina 223 (10.3)
Citizen
Malaysian 1953 (90.6)
Non Malaysian 203 (9.4
Employment 1356 (62.9) 41 (36.3) 1.00 (2.01;4.41) 31.050 1 <0.001
Employed 800 (37.1) 72 (63.7) 2.977 29.548 1 <0.001
Unemployed
aLikelihood Ratio (LR) test
bWald test
Comorbidities of COVID-19 cases upon diagnosis
Hypertension, diabetes mellitus, obesity and other diseases such as asthma, cancer
or any other chronic diseases were analyzed. There were noted to have 12.4% of
the cases have hypertension and was categorized in severe clinical outcome. Other
comorbidities contributed less than 10% respectively in severe clinical outcome.
41
From all of the above mentioned comorbidities, there were no significant association
with severe COVID-19 disease (Table 2).
COVID-19 disease related characteristics
In terms of COVID-19 related characteristics such as COVID-19 vaccination status,
unvaccinated cases significantly reported to have 61.1% severe clinical outcome
association as compared to those completed two doses of COVID-19 vaccine. Other
than that, having symptoms was also contributed 92.9% of severe clinical outcome
cases have significant association (p<0.001). Screening at workplace and other
screening categories (hospital pre-admission and pre-placement of inmates) were
found to be protectively associated with clinical outcome (Table 3)
Risk factors associated with COVID-19 disease
From bivariate analysis, several factors (Table 4) were found to be associated with
severe disease. After adjusting these variables in multivariate complete case
analysis model, using Stepwise procedure, severe clinical outcome was found to be
56 times higher in those age 60 years and more (aOR, 56.4; 95% CI, 12.61-252.38)
followed by those in age group of 46 to 59 years old (aOR, 7.31; 95% CI, 1.59-33.62).
Unvaccinated COVID-19 patients were found to be 2.7 times more at risk of having
severe clinical outcome (aOR, 2.7; 95% CI, 1.56-4.69) as compared to fully
vaccinated with two doses of COVID-19 vaccine cases.
Having symptoms upon diagnosis of COVID-19 was also strongly a risk factors in
developing severe clinical outcome as compared to those with asymptomatic cases
(aOR, 10.03; 95% CI, 4.34-23.20). Close contact screening and screening at
workplace (scheduled) were found to be a protective factors as compared to those
had their screening due to presence of COVID-19 symptoms alone. All of the factors
that included in the final model were tested for interactions, with no interaction were
found in all of the variables. The multicollinearity in all of the variables were checked
and resulted to have VIF of less than 10. Hosmer-Lemeshow goodness-of-fit test
was also done and found to be not significant and 96.4% of cases were predicted
correctly whether they have severe clinical outcome or mild clinical outcome.
42
Table 2: Comorbidities of COVID-19 cases upon diagnosis
Clinical Outcome Crude (95% CI
n (%) OR OR)
Variables (Severe) X2 df p-
Mild Severe 2.694 valuea
Hypertension 3.013
Yes 1 0.101
No
168 (7.8) 14 (12.4) 1.00 (0.33; 1.07) 1 0.083
1988 (92.2) 99 (87.6) 0.60 1 0.829
Diabetes Mellitus 0.047
Yes 123 (5.7) 7 (6.2) 1.00
No 2033 (94.3) 106 (93.8) 0.92 (0.42;2.01) 0.048 1 0.827
1 0.171
Obesity 1.873
Yes 115 (5.3) 3 (2.7) 1.00
No 2041 (94.7) 110 (97.3) 2.07 (0.64;6.61) 1.497 1 0.221
1 0.717
Others 0.132
Yes 152 (7.1) 9 (8.0) 1.00
No 2004 (92.9) 104 (92.0) 0.876 (0.44;1.77) 0.136 1 0.712
aLikelihood Ratio (LR) test
bWald test
Table 3: COVID-19 disease related characteristics
Variables Clinical Outcome Crude (95% CI df p-
n (%) OR OR) X2 valuea
(Severe)
Mild Severe
Vaccination status 7.631 1 0.006
Yes 1126 (52.2) 44 (38.9) 1.00
No 1030 (47.8) 69 (61.1) 1.71 (1.16; 7.435 1 0.006
2.53)
Symptoms 69.753 1 <0.001
Yes 1236 (57.3) 105 (92.9) 9.77 (4.74; 38.081 1 <0.001
20.15)
No 920 (42.7) 8 (7.1) 1.00
Type of screening 36 (31.9) 1.00 42.524 3 <0.001
38 (33.6) 0.75
Symptomatic 380 (17.6) 11 (9.7) 0.29
28 (24.8) 0.12
Close contact 1029 (47.7) (0.45;1.27) 1.160 1 0.282
(0.18;0.49) 22.349 1 <0.001b
Workplace 525 (24.4) (0.08;0.34) 24.221 1 <0.001b
Other 222 (10.3)
aLikelihood Ratio (LR) test
bWald test
43
Table 4: Risk factors associated with COVID-19 disease severity
Variables Adj. OR (95% CI OR) X2 df p-valuea
(0.59;11.58) 89.834 3 <0.001
Age Group 1.00 0.209
13-18 years old 2.60 1.576 1 0.011b
19-45 years old <0.001b
46-59 years old 7.31 (1.59;33.62) 6.525 1 <0.001
60 years old and more 56.40 (12.61;252.38) 27.823 1 <0.001
Vaccination status <0.001
Yes 1.00 <0.001
0.004b
No 2.70 (1.56;4.69) 12.529 1 0.150b
Symptomatic
Yes 10.03 (4.34;23.20) 29.054 1
No 1.00
Type of screening 38.440 3
Symptomatic 1.00
Close contact 0.21 (0.11;0.42) 20.695 1
Workplace 0.28 (0.12;0.67) 8.290 1
Other 1.75 (0.82;3.77) 2.076 1
aLikelihood Ratio (LR) test
bWald test
DISCUSSIONS
This study is the first study done in Kulim district for all laboratory-confirmed COVID-
19 cases that peaked starting in August 2021 until December 2021. Malaysia
implemented serial policies including extensive contact tracing, expedited laboratory
testing, compulsory home or low risk quarantine center or hospital quarantine for
those suspected for COVID-19, and instituted movement control order for the public
which were made possible by the normative legal acts: Prevention and Control of
Infectious Diseases Act 1988 and the Police Act 1967 (Tang, 2020). Malaysia did
report up to 92% having mild diseases with a low case fatality rate of 1.2%. These
findings were similar to other reports (Guan et al., 2020; Richardson et al., 2020; Liu
et al., 2020). Older groups were mostly symptomatic, and for those with
comorbidities, the likelihood of progressing to poorer outcomes was high (Petrilli et
al., 2020; Williamson et al., 2020).
The largest group of age that have been affected were from 19 to 45 years of age.
This has similar findings with recent national study done in 2020 (Sim et al., 2020).
However, those who progressed into severe clinical outcome were from them who
44
age 60 years old and above. This corresponce with other studies in European
countries (Karadag, 2020). From the descriptive analysis above, malay ethnicity
contributed more than half of the cases of COVID-19 in Kulim district. This is due to
the local distribution of the ethnicity where malay is the majority ethnicity not only in
Kulim, but all over Malaysia. Hence the percentage affected were high. However,
ethnicity were not a risk factor of having severe COVID-19 disease. Unemployed
was found to be significantly associated with severe COVID-19, however it was not
a risk factor to developed severe COVID-19.
COVID-19 vaccine was first introduced in Malaysia in early March 2021 targetting
the frontliners, patients of chronic diseases and elderly age 60 and above. COVID-
19 vaccine was found to be effective after being approved by the World Health
Organization in the end of year 2020. In this study, the findings showed unvaccinated
COVID-19 cases have 2 times at risk of getting severe disease. Other studies
worldwide did have similar findings where vaccination status contribute largely in
disease severity (Evans & Jewell, 2021; Amirthalingam, 2021; Braeye, 2021).
Symptoms of COVID-19 ranging from a simple sorethroat, to difficulties in breathing
were taken into account in this study. These symptoms include cough, runny nose,
fever, anosmia, ageusia, headache, abdominal pain, diarrhea, and chest pain.
Having symptoms at time of diagnosis showed to have 10 times at risk of developing
severe clinical outcome. Multiple studies worldwide such as in China reported that
having chesty cough (expectoration) was an independent risk factors of COVID-19
disease severity (Zhang et al., 2020). A pooled analysis study by Brandon et al.
(2020) reported that abdominal pain, which was reported in three studies (n = 731)
was significantly associated with increased COVID-19 severity (OR 3.93 [95% CI
1.64–9.38).
Most of the close contact of a COVID-19 case were asymptomatic or only having
mild and unnoticable symptoms (Wu & McGoogan, 2020). Therefore screening of
the close contact eventhough they are asymptomatic were found to be a protective
factor. Early detection will lead to early treatment and may prevent COVID-19
disease to progress into more severe form. Scheduled screening at workplace was
also advised by the WHO as one of the prevention tools of COVID-19 spread in the
community (Gidengil et al., 2020). Similar reason of early detection is to prevent
severe disease outcome. This study unable to take into account several other
variables that was appropriate to be studied such as pregnancy, poverty,
overcrowding and uses of certain medications (Wei et al., 2020; Booth et al., 2021).
This was due to the availability of the variables that were documented. Other than
45
that, time and budget constraint were also one of the limitations of this study.
However, the final choice of analysis did help to eliminate confounders, if any.
CONCLUSION
Age 60 years and more, unvaccinated, symptomatic upon first diagnosis are among
the risk factors contributed towards severe clinical outcome of COVID-19. Thus,
protecting the elderly, completed vaccination of COVID-19, and early screening
should be emphasized in managing COVID-19 to prevent severe clinical outcome.
ACKNOWLEDGEMENT
The authors would like to thank the Director General of Health Malaysia for his
permission to publish this paper. We acknowledge all healthcare workers involved
in the treatment, prevention and control programme of COVID-19 in Kulim district.
REFERENCES
Amirthalingam, G., Bernal, J. L., Andrews, N. J., Whitaker, H., Gower, C., Stowe, J., ... &
Ramsay, M. E. (2021). Serological responses and vaccine effectiveness for
extended COVID-19 vaccine schedules in England. Nature communications, 12(1),
1-9.
Awang, H., Yaacob, E. L., Syed Aluawi, S. N., Mahmood, M. F., Hamzah, F. H., Wahab, A.,
... & Yunus, N. A. (2021). A case–control study of determinants for COVID-19
infection based on contact tracing in Dungun district, Terengganu state of Malaysia.
Infectious Diseases, 53(3), 222-225.
Booth, A., Reed, A. B., Ponzo, S., Yassaee, A., Aral, M., Plans, D., ... & Mohan, D. (2021).
Population risk factors for severe disease and mortality in COVID-19: A global
systematic review and meta-analysis. PloS one, 16(3), e0247461.
Braeye, T., Cornelissen, L., Catteau, L., Haarhuis, F., Proesmans, K., De Ridder, K., ... &
Van Cauteren, D. (2021). Vaccine effectiveness against infection and onwards
transmission of COVID-19: Analysis of Belgian contact tracing data, January-June
2021. Vaccine, 39(39), 5456-5460.
Centers for Disease Control and Prevention (CDC). (2021, December 17). Vaccine
Breakthrough Infections: The Possibility of Getting COVID-19 after Getting
Vaccinated. https://www.cdc.gov/coronavirus/2019-
ncov/vaccines/effectiveness/why-measure-effectiveness/breakthrough-cases.html
Dean, A., Sullivan, K. M., & Minn, M. S. (2009). OpenEpi: A Web-based Epidemiologic and
Statistical Calculator for Public Health. Public Health Reports, 124(3), 471.
https://doi.org/10.1177/003335490912400320
Elengoe, A. (2020). COVID-19 outbreak in Malaysia. In Osong Public Health and Research
Perspectives (Vol. 11, Issue 3, pp. 93–100). Korea Centers for Disease Control and
Prevention. https://doi.org/10.24171/j.phrp.2020.11.3.08
46
Evans, S. J., & Jewell, N. P. (2021). Vaccine effectiveness studies in the field. New England
Journal of Medicine, 385(7), 650-651.
Gidengil, C. A., Fischer, S. H., & Broten, N. (2020). A Framework for Evaluating Approaches
to Symptom Screening in the Workplace During the COVID-19 Pandemic. RAND.
Guan, W. J., Ni, Z. Y., Hu, Y., Liang, W. H., Ou, C. Q., He, J. X., ... & Zhong, N. S. (2020).
Clinical characteristics of coronavirus disease 2019 in China. New England journal
of medicine, 382(18), 1708-1720.
Henry, B. M., de Oliveira, M. H. S., Benoit, J., & Lippi, G. (2020). Gastrointestinal symptoms
associated with severity of coronavirus disease 2019 (COVID-19): a pooled analysis.
Internal and emergency medicine, 15(5), 857-859.
Hashim, J. H., Adman, M. A., Hashim, Z., Mohd Radi, M. F., & Kwan, S. C. (2021). COVID-
19 Epidemic in Malaysia: Epidemic Progression, Challenges, and Response.
Frontiers in Public Health, 9, 247.
https://doi.org/10.3389/FPUBH.2021.560592/BIBTEX
Jayaraj, V. J., Rampal, S., Ng, C.-W., & Chong, D. W. Q. (2021). The Epidemiology of
COVID-19 in Malaysia. The Lancet Regional Health - Western Pacific, 17, 100295.
https://doi.org/10.1016/J.LANWPC.2021.100295/ATTACHMENT/ED78EFDB-7456-
4CEE-8F99-4CA08D7DF0E8/MMC1.DOCX
Karadag, E. (2020). Increase in COVID‐19 cases and case‐fatality and case‐recovery rates
in Europe: A cross‐temporal meta‐analysis. Journal of medical virology, 92(9), 1511-
1517.
Kulim District Office. (2021, December 27). Pergerakan 14 Hari Taburan Kes COVID-19
Mengikut Mukim Daerah Kulim .
https://web.facebook.com/PejabatKesihatanDaerahKulim?_rdc=1&_rdr
Lipsitch, M., Swerdlow, D. L., & Finelli, L. (2020). Defining the Epidemiology of Covid-19 —
Studies Needed. New England Journal of Medicine, 382(13), 1194–1196.
https://doi.org/10.1056/NEJMP2002125/SUPPL_FILE/NEJMP2002125_DISCLOS
URES.PDF
Liu, Y., Mao, B., Liang, S., & Yang, J. W., Lu, H.‐W., Chai, Y.‐H., & Xu, J.‐F.(2020).
Association between age and clinical characteristics and outcomes of COVID‐19.
European Respiratory Journal, 55(5), 2001112.
Ministry of Health (MOH) Malaysia. (n.d.). COVIDNOW in Malaysia - COVIDNOW. Retrieved
January 9, 2022, from https://covidnow.moh.gov.my/
Ministry of Health (MOH) Malaysia. (2021). Clinical Guidelines on COVID-19 Vaccination in
Malaysia . https://www.nih.gov.my/covid-19/component/content/article/92-e-
books/215-clinical-guidelines-on-covid-19-vaccination-3rd-edition-by-ministry-of-
health-malaysia?Itemid=437
Petrilli, C. M., Jones, S. A., Yang, J., Rajagopalan, H., O'Donnell, L. F., Chernyak, Y., ... &
Horwitz, L. I. (2020). Factors associated with hospitalization and critical illness
among 4,103 patients with COVID-19 disease in New York City. MedRxiv.
Richardson, S., Hirsch, J. S., Narasimhan, M., Crawford, J. M., McGinn, T., Davidson, K.
W., ... & Northwell COVID-19 Research Consortium. (2020). Presenting
characteristics, comorbidities, and outcomes among 5700 patients hospitalized with
COVID-19 in the New York City area. Jama, 323(20), 2052-2059.
47
Shah, A. U. M., Safri, S. N. A., Thevadas, R., Noordin, N. K., Rahman, A. A., Sekawi, Z.,
Ideris, A., & Sultan, M. T. H. (2020). COVID-19 outbreak in Malaysia: Actions taken
by the Malaysian government. International Journal of Infectious Diseases, 97, 108–
116. https://doi.org/10.1016/j.ijid.2020.05.093
Sim, B. L. H., Chidambaram, S. K., Wong, X. C., Pathmanathan, M. D., Peariasamy, K. M.,
Hor, C. P., ... & Goh, P. P. (2020). Clinical characteristics and risk factors for severe
COVID-19 infections in Malaysia: A nationwide observational study. The Lancet
Regional Health-Western Pacific, 4, 100055.
Taib, N. A. A., Raja, D. B., Teo, A. K. J., Kamarulzaman, A., William, T., Arvinder-Singh, H.
S., ... & Amir, L. E. (2022). Characterisation of COVID-19 deaths by vaccination types
and status in Malaysia between February and September 2021. The Lancet Regional
Health–Western Pacific, 18.
Tang, K. H. D. (2020). Movement control as an effective measure against Covid-19 spread
in Malaysia: an overview. Journal of Public Health, 1-4.
Tenforde, M. W., Self, W. H., Adams, K., Gaglani, M., Ginde, A. A., McNeal, T., Ghamande,
S., Douin, D. J., Talbot, H. K., Casey, J. D., Mohr, N. M., Zepeski, A., Shapiro, N. I.,
Gibbs, K. W., Files, D. C., Hager, D. N., Shehu, A., Prekker, M. E., Erickson, H. L.,
… Patel, M. M. (2021). Association Between mRNA Vaccination and COVID-19
Hospitalization and Disease Severity. JAMA, 326(20), 2043–2054.
https://doi.org/10.1001/JAMA.2021.19499
Williamson, E. J., Walker, A. J., Bhaskaran, K., Bacon, S., Bates, C., Morton, C. E., ... &
Goldacre, B. (2020). Factors associated with COVID-19-related death using
OpenSAFELY. Nature, 584(7821), 430-436.
Wei, Y. Y., Wang, R. R., Zhang, D. W., Tu, Y. H., Chen, C. S., Ji, S., ... & Fei, G. H. (2020).
Risk factors for severe COVID-19: Evidence from 167 hospitalized patients in Anhui,
China. Journal of Infection, 81(1), e89-e92.
Wu, Z., & McGoogan, J. M. (2020). Characteristics of and important lessons from the
coronavirus disease 2019 (COVID-19) outbreak in China: summary of a report of 72
314 cases from the Chinese Center for Disease Control and Prevention. Jama,
323(13), 1239-1242.
Zhang, J., Wang, X., Jia, X., Li, J., Hu, K., Chen, G., ... & Dong, W. (2020). Risk factors for
disease severity, unimprovement, and mortality in COVID-19 patients in Wuhan,
China. Clinical microbiology and infection, 26(6), 767-772.
48
PEMERKASAAN KOMUNITI: PERSEDIAAN UNTUK HIDUP
BERSAMA VIRUS COVID 19!
Juita J.1, Eliana A.2, Suziana R.2
1Unit Promosi Kesihatan, Pejabat Kesihatan Daerah Kuala Muda
2Pejabat Kesihatan Daerah Kuala Muda
Corresponding author e-mail: [email protected]
ABSTRAK
Latarbelakang: Pemerkasaan komuniti adalah satu proses membina upaya
komuniti supaya mereka dapat meningkatkan kawalan ke atas kehidupan mereka.
Apabila komuniti diperkasakan, komuniti tesebut dapat memainkan peranan penting
dalam membangunkan komuniti setempat menerusi penglibatan komuniti dan
tindakan kolektif komuniti dalam menangani masalah setempat serta memenuhi
defisit hidup. Secara mudahnya komuniti mengenalpasti masalah yang wujud dalam
komuniti, menilai masalah tersebut, merancang strategi bagi mengatasi masalah
tersebut dan mengawal selia masalah agar tidak berulang.
Metodologi: Kualitatif menggunakan pendekatan naratif berdasarkan pengalaman
dalam menjalankan aktiviti pemerkasaan komuniti di daerah Kuala Muda sepanjang
tahun 2021. Pelbagai aktiviti promosi kesihatan yang telah dijalankan sepanjang
pandemik ini dengan pelbagai kaedah, saluran, medium dengan advokasi pelbagai
agensi untuk mendidik dan mengajak penduduk untuk bersedia hidup secara norma
baru sebagai jalan keluar untuk hidup bersama virus ini. Hasilnya walaupun tidak
dapat diukur secara saintifik namun dapat dilihat daripada sudut lain dengan liputan
peratusan vaksinasi, kedatangan secara terus ke Pusat Pemberian Vaksin,
kedatangan secara terus ke Covid Assesment Centre, kedatangan secara terus ke
Khemah Saringan COVID 19 dan Pematuhan dalam Pemantauan SOP.
Rumusan: Pemerkasaan komuniti ini bukanlah sesuatu yang mudah tetapi bukan
sesuatu yang mustahil untuk dicapai kerana setiap sesuatu itu bermula daripada kita
iaitu setiap individu yang mewakili komuniti tersebut.
Katakunci: pemerkasaan komuniti, noma baharu, promosi kesihatan
49
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Laporan Teknikal Jabatan Kesihatan Negeri Kedah 2022
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