Laporan Teknikal Jabatan Kesihatan Negeri Kedah 2022

Table 2: Vaccine status of the mortality cases n (%) Mean (SD)
Variables
153 (72.9)
Vacccine status (N=210) 23 (11.0)
Unvaccinated 34 (16.2)
Incomplete
Complete

Characteristics for unvaccinated case (N=153) 6 (3.9) 62.2(±15.1)
Age group 14 (9.2)
<30 15 (9.8)
31-40 29 (19.0)
41-50 36 (23.5)
51-60 53 (34.6)
61-70
>70 138 (90.2)
Race 5 (3.3)
Malay 4 (2.5)
Non-Malaysian 3 (2.0)
Chinese 3 (2.0)
Indian
Siamese 77 (50.3)
Gender 76 (49.7)
Male
Female

Table 3: Types of screening for Covid-19 diagnosis among mortality cases

Type of screening n (%)
Cluster screening 30 (14.3)
Symptomatic screening 86 (40.9)
Hospital screening 30 (14.3)
Mortality screening
Self-screening 7 (3.3)
Close contact screening 4 (1.9)
Severe Acute Respiratory Illness (SARI) screening 52 (24.8)
1 (0.5)

The types of screening for Covid-19 diagnosis among mortality cases were shown
in Table 3. Most of the mortality cases were diagnosed as Covid-19 through
symptomatic screening 86 (40.9%) cases followed by close contact screening 52
(24.8%) cases, cluster and hospital screening with 30 (14.3%) cases each, mortality

100

screening 7 (3.3%) cases, self-screening 4 (1.9%) and 1 (0.5%) case through SARI
screening.

Table 4 shows number of Covid-19 Assessment Centre (CAC) attendees among the
mortality cases and the category of initial assessment. Among the mortality cases,
only 41 (19.5%) cases had come for assessment at CAC. Those who had been
assessed mostly falls under category 4 with 20 (48.9%) cases. Table 5 shows the
casue of the death. From the data collected, most of the mortality cases are due to
pneumonia with counted 205 (97.5%) cases.

Table 4: Number of Covid-19 Assessment Centre (CAC) attendees among the

mortality cases and the category of initial assessment.

Covid-19 Assessment Centre Attendees n (%)

Absent 169 (80.5)

Present 41 (19.5)

Category during assessment

Category 1a 4 (9.8)

Category 2b 14 34.1)

Category 3c 2 (4.9)

Category 4d 20 (48.9)

Category 5e 1 (2.3)

a. Category 1: Asymptomatic.
b. Category 2: Symptomatic, no pneumonia.
c. Category 3: Symptomatic with pneumonia and need treatment and observation at hospital.
d. Category 4: Symptomatic with pneumonia and need oxygen support.
e. Category 5: Critically ill with multiorgan involvement.

Sources: Ministry of Health, Malaysia.

Table 5: Cause of death. n (%)
Cause of death 205 (97.5)
Covid-19 pneumonia
Drowning in a man with covid-19 1 (0.5)
Perforated duodenal ulcer in a man with coronary atherosclerosis 1 (0.5)
and covid-19
Septic shock secondary to urosepsis with covid-19 1 (0.5)
Carbapenem-resistant Enterobacteriaceae bacteremia with 1 (0.5)
covid-19 and underlying Systemic Lupus Erythematosus
Sepsis secondary to meliodosis with covid-19 1 (0.5)

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Brought-in-dead (BID) cases
Kubang Pasu District had recorded 22 BID cases in the year 2021. The
characteristics of the BID cases are shown in Table 6 below:

Table 6: Characteristics of BID cases. n (%) Mean(SD)
Variables (N=22) 62.2 (±15.1)
Gender 11 (50.0%)
Male 11 (50.0%)
Female
Age group 2 (9.1)
31-40 2 (9.1)
41-50 5 (22.7)
51-60 5 (22.7)
61-70 8 (36.4)
>70
Race 19 (86.5)
Malay 1 (4.5)
India 1 (4.5)
Chinese 1 (4.5)
Non-Malaysian
Vaccine status 19 (86.5)
Unvaccinated 1 (4.5)
Incomplete 2 (9.0)
Completed

DISCUSSIONS

The ongoing epidemic of coronavirus disease 2019 (COVID-19) is devastating,
despite extensive implementation of control measures. It gives a significant impact
to the health systems and community which includes health services and the number
of cases and mortality. In this study, we could not further describe the risk of death
by the types of comorbidities. Nevertheless, other studies in Malaysia have reported
that persons with diabetes, hypertension, kidney diseases, heart diseases, and
cancer were at higher risk of COVID-19-related deaths (Taib et al., 2022). According
to statistics from 26 countries, adults aged 70 and above account for 37 percent of
COVID-19-related mortality in low- and middle-income countries, compared to 87
percent in high income countries (Demombynes, 2020). The highest cases of
mortality due to Covid-19 in Kubang Pasu District occurs among the group age of
more than 70 years old which cover 34.8%. Patient comorbidities such as
hypertension, diabetes, and obesity have been shown to be associated with higher

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COVID-19 mortality (Imam et. al., 2020). Since the number of comorbid conditions
steadily increases with age, this could be another possible explanation of the
observed increased mortality in older patients. While disease mortality is higher in
the elderly in other conditions like cardiovascular disease, changes associated with
immunosuppress might explain the increased vulnerability to infection and the
disproportionately high mortality due to COVID-19 in older patients (Kang and Jung,
2020).

Most of the mortality cases in Kubang Pasu District occurs among Malay ethnicity.
Studies from other countries have identified many factors that influence the
acceptance of the COVID-19 vaccine. These include risk perception of the disease,
perception of vaccine safety and efficacy, general vaccination attitudes. Past
vaccination history, doctors’ recommendation, vaccination costs, vaccination
convenience and sociodemographic characteristics (Wang et al., 2020, Al-Mohaithef
et al., 2020). Malay ethnicity had always been related with Islam and most of them
are Malay. Malaysia, a multi-cultural and multi-faith country, is an example of how
religious beliefs could strongly influence health behaviours at individual and
community levels. Religion might facilitate or hinder the adherence to public health
measures to prevent the spread of COVID-19. On one hand, religion could mediate
adherence to preventive measures through the moral principles of doing no harm
and protecting the interest of fellow citizens, and compliance to authorities such as
the government; on the other hand, people who are more religious might perceive
greater divine support and hence feel invincible to COVID-19 (DeFranza et al.,
2020). Refusal of religious adherents to be screened for COVID-19 because of
religious teaching or stigmatization was common. The members of the Shincheonji
Church, which accounted for almost 50% of all COVID-19 cases in Korea, believed
that their spirit and bodies are immortal and this may have led them to refuse testing
even when they had symptoms (Kim et al., 2020). Religious leaders could play a role
in encouraging and providing spiritual and mental support to their congregants to
attend COVID-19 testing or seek medical help when there are symptoms. For
example, they could quote the Holy Scriptures regarding seeking medical care when
one is sick (Featherstone, 2015).

Amidst the COVID-19 outbreak, misinformation about COVID-19 was shared
extensively in social media. About 20% of misinformation was spread by prominent
public figures such as politicians but it attracted 69% of social media engagement
(Brennen et al., 2020). Religious leaders, because of their prominent role, could play
a part in dispelling COVID-19 misinformation. The Ministry of Health could work with
religious leaders in countering misinformation and disseminate scientifically correct
and religiously acceptable messages to the congregants. Since religions teach

103

honesty, it could be used as a resource to encourage truthful sharing of information.
A study of found that a simple accuracy reminder at the beginning of the study
increased the likelihood that the participants would share true information related to
COVID-19 (Pennycook et al., 2020).

Vaccine had been shown to reduce symptomatic disease, hospitalisations,
severe/critical disease and death after the second dose (Glatman-Freedman et. al.,
2021). From this short study, 153 (79.2%) of the cases were unvaccinated which is
quite alarming knowing that most of them are old age. Control measures such as
using masks, maintaining social distance, screening of symptomatic people, tracing
contacts, and quarantine have yielded promising results (Huang et al., 2022).
However, these measures are subject to cooperation between the state and the
public (Lai et al., 2020). The above measures are not sufficient to completely control
the spread of the pandemic, and the development of vaccines cannot be delayed.
Various vaccines have been developed by multiple countries. After a series of
efficacy and safety assessments, vaccinations have been carried out in several
countries. The purpose of the vaccine itself is to reduce hospitalization, severe
illness, and mortality to those who affected (Huang et al., 2022). According to a
systematic review and meta-analysis by Huang et al. (2022), irrespective of what
vaccine or brand of vaccine is administered, there are significant differences in the
number of severely ill hospitalized patients between the vaccinated and non-
vaccinated groups. However, vaccine hesitancy was named as one of the top 10
threats to global health by the WHO in 2019. This was in response to a reduction in
global immunisation rates for the measles, mumps and rubella vaccine, which
slipped to 85% compared to the required target of 95% and led to numerous measles
outbreaks (Robertson et al., 2021). The reluctance and refusal of the COVID-19
vaccine is a global problem. Furthermore, to have a substantial population
immunised to achieve herd immunity, reasons for vaccine hesitancy must be
addressed. Vaccines could prevent the risk of severe illness after diagnosis.
Implementing pandemic prevention policies in the country and procuring vaccines
will help improve vaccine coverage to reduce the number of deaths from COVID-19.

When a case investigation is conducted, a more detailed emphasis was placed to
identify all close contacts to positive cases, including close family as well as social
contacts. With the increase in the number of cases, contact tracing process
becoming more difficult, we hypothesise that this increase could be attributed to poor
healthcare-seeking behaviour among the Kubang Pasu district community, which
could be due to a lack of knowledge about the disease, perception of the illness,
stigma associated with the disease, readily available drug stores aiding self-

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medication, as well as misconceptions about the severity of the disease due to the
disease's relative high prevalence. We urge that investigations on the population's
views of COVID-19 be conducted to investigate the determinants of the reported
poor health seeking behaviour.

At the early stage of pandemic, screening test was done to looks for individual
infections in a group even if there is no reason to suspect those individuals are
infected. Screening involves testing asymptomatic individuals who do not have
known or suspected exposure to COVID-19 in order to make individual decisions
based on the test results. At the later stage, diagnostic testing was done to identify
current infection at the individual level and is performed when a person has signs or
symptoms of infection, or when a person is asymptomatic but has recent known or
suspected exposure. It is important to note that testing, even serial testing, is of
limited value if it is not combined with appropriate mitigations for individuals who test
positive (such as quarantine), good contact tracing, and effective behavioral
protocols (such as mask wearing, hand washing and social distancing), even for
individuals who test negative. We further urge that community awareness and
involvement programmes for COVID-19 prevention and management be ongoing
and successful.

The large number of cases at a time may contribute to the delay of the ambulance
service to pick up patients for treatment. Therefore, cooperation with private
ambulance services/non-governmental organizations (NGOs) is expected to
overcome this problem. Health personnel should also be constantly aware of the
latest protocols related to the management of patients present with symptoms of
Influenza-like illness (ILI). Continuing medical education especially involving the staff
working in the relevant units needs to be done periodically.

As a result of the analysis, several factors have been identified to contribute to the
occurrence of brought-in-dead (BID) cases. Among the factors that have been
identified are the patient's delay in seeking treatment when symptoms begin; with
this factor was found in 15 cases (68.2%) out of 22 BID cases reported. Failure to
identify close contacts when conducting case investigations has also been found to
be among the factors contributing to BID cases, with a total of 3 cases (13.6%) found
to be related to those factors. Furthermore, sub-optimal close contact monitoring as
well as delays in obtaining an ambulance following the high case load in PKDs and
hospitals also contributed to the BID cases with each being linked in 2 cases (9.0%)
of BIDs. In addition, weaknesses in ILI case management were identified to
contribute to 1 case (4.5%) of BID. COVID-19 proliferation has been aided by
increasing human-to-human transmission and a failure to implement preventative

105

measures (MacIntyre, 2020). In order to reduce the number of BID cases, remedial
measures need to be taken at each phase related to disease management and
control. Among them, public awareness on the importance of seeking early treatment
should be applied to each individual.

Strength and weakness
Knowing the characteristics of the mortality cases is the district is important for
planning of the activities for health promotion and intervention to reduce the number.
Through this study we can detect the shortfall that happen in our daily activities in
intervention to reduce the amount of mortality. There are few of incomplete
investigation form and need to reconfirmed with the family members. This will
introduced to recall bias in doing this study. There is also limitation in getting
comorbid of the cases due to incomplete data in the surveillance. The comorbidity
data is very important to complete the characteristics of the mortality cases.

CONCLUSION

The highest number of mortality cases occur among those with age more than 70. It
involved mostly among Malay race and they were unvaccinated. Protecting group of
age Lung complication is the main cause of death since most of the mortality cases
passed away due to pneumonia. This high number of mortality and BID cases might
be attributed to poor health-seeking behaviour among the Kubang Pasu population
with COVID-19. We therefore recommend that studies on the perceptions of the
Kubang Pasu population regarding COVID-19 be carried out to determine the drivers
of the observed poor health seeking behaviour. Promotion activities about Covid-19
and vaccine should be strengthened further to improve the knowledge and action
towards Covid-19 in community.

ACKNOWLEDGEMENT

The authors would like to thank the Director General of Health Malaysia for his
permission to publish this paper. We sincerely expressed our gratitude to the
respected Kedah Health Director and all the staff in Kubang Pasu Health District
Office for the kind help and effort in completing the data collection and the
opportunity to learn and gain the writing experience through this article. This article
had been registered in National Medical Research Registry (NMRR) with an ID:
RSCH ID-21-01721-ATX.

106

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STRENGTHENING OF GATESCREENING & STANDARD
OPERATING PROCEDURE (SOP): A LESSON LEARN FROM
CROSS-SECTIONAL STUDY ON COVID-19 OUTBREAK AT

TRAINING INSTITUTION KUBANG PASU DISTRICT

Ikhwan MI1*, Zukri MI2, Ku Saifullah1,Mohd Faiz3, Affiz2

1Department of Community Medicine, School of Medical Sciences, Health Campus, University
Sains Malaysia, Kubang Kerian, Kelantan, Malaysia
2Kubang Pasu District Health Office
3Department of Community Medicine, School of Medical Sciences, Health Campus, Universiti Putra
Malaysia
*Corresponding author: Muhammad Ikhwan Bin Ismail, Email: [email protected]

ABSTRACT
Background: Covid-19 Is an Illness caused by a novel (new) coronavirus now called
severe acute respiratory syndrome coronavirus, which was first detected from an
outbreak of respiratory illness in Wuhan City, Hubei Province, China. 1st case in
Malaysia was reported on 25 Jan 2020 and subsequently, multiple cases and the
outbreak have been reported. An opening of the education sector has proven to
cause a high risk of disease transmission among students, especially those sharing
the same close environment as a hostel. To reduce the risk among students as
ensure the quality of the education process, gatekeeping screening and adherence
toward standard operating procedures (SOP) may play a crucial role. Thus
gatekeeping for the students before starting and during physical attended class
based on certain criteria may be appropriate. This study may highlight the
importance of gatekeeping and adherence to SOP in reducing the risk of infection.
By knowing the mitigating method may improvise the strategy in controlling the
spreading of the disease, especially in an institution.
Methodology: This is a descriptive analysis involving a formal outbreak
investigation started upon multiple cases of Covid-19 confirmed case with rapid link
reported from Training Institution from 1st of November 2021 until 26 December
2021. An epic curve was applied to demonstrate the chronology of the case and
relevant events related to the outbreak. A Scatter plot used to demonstrate the
relation CT value and duration of onset or exposure
Results: First onset reported on 3rd November 2021. 113 students identified as
close contact. A diagnostic test run reveals 34 positive lab confirmed cases. No
compulsory quarantine upon student entry, and unsupervised swab test among
students may increase the risk of Covid-19 transmission upon opening of the
institution.
Conclusion: Gatescreening involving staggered student entry, compulsory
quarantine, universal masking, and physical distancing is the key point in mitigating
the risk of Covid-19 infection.

Keyword: Covid-19, gatescreening, standard operating procedure, Outbreak,
Training Institution

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INTRODUCTION

Covid-19 infection is an illness caused by a novel (new) coronavirus now called
severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2; formerly called
2019-nCOV), which was first detected from an outbreak of respiratory illness in
Wuhan City, Hubei Province, China. Covid-19 was declared a pandemic in March
2020 (Cucinotta and Vanelli, 2020). Since then every country on the same page in
eliminating Covid-19.

The current global burden shows the rising of Covid-19 cases with 7-day averages
estimated at 3.3milion cases reported since December 2021 (Worldometer, 2022).
This may link to the newly detected omicron variant in November 2021 which is
known to have the property of easily spread among the community (CDC, 2021a).
One of the burdens from the rising of Covid-19 cases is toward the educational
institution due to risk of outbreak occurrence (Sebastiani and Palù, 2020). To ensure
the safety of the schooling process, there is justifiable for proper gatescreening.

Gatescreening and adherence toward SOP are the most important steps in
preventing the Covid-19 cluster in the institution. Gatescreening is ineffective to
mitigate the Covid-19 cluster once the Covid-19 cases are introduced in the
institution, especially in an environment with a moderate and higher risk of
transmission (Tupper and Colijn, 2021). Some countries have introduced several
actions to prevent Covid-19 transmission at gate levels such as temperature and
symptom screening on arrival, designation of specific and multiple entrances into the
school, no family member allowed to enter the gate, staggered arrival and
dismission, travel reports from parents, and encourage own transportation or regular
cleaning on public transports (Melnick and Darling-Hammond, 2020). Regular
pooled Covid-19 testing is also used to detect infection among students earlier, with
using universal testing that confirms the infection within several hours being
preferred than the testing done at a centralized laboratory (Tupper and Colijn, 2021).
To reduce the risk of transmission from the student to the staff, the institution is
advised to provide an adequate human resource for the gatekeeping activities, and
the staff is equipped with adequate personal protective gear during screening the
students at the gate level (Weijer et al., 2021).

To date, Malaysia has been led by National Security Council (MKN) in managing the
Covid-19. However various ministries especially the Ministry of Health involved as
the backbone in mitigating the risk of infection. There are 4 phase levels of the new
norm proposed by MKN for the National Recovery Plan (NRP) based on the new
case reported, ICU bed occupied and adult vaccination status (MPN, 2021). In
educational sector, all private and government education institutional closed and

110

only virtual class allowed throughout the phase 1. However, for phase 2, its been
more flexible where it allow student that sit for examination to attend physical class
with proper SOP. Phase 3 and phase 4 share similar SOP where it allow an pening
of all primary and secondary educational institution for physical attended class with
a physical and wearing mask during class session as long student are asymptomatic
and low risk (MKN, 2021b). As being in phase 4, for Higher education in the state
of Kedah, they are allowed to operate an institution as physically attended with a
strictly physical distancing and wearing a mask (MKN, 2021a). However, the Training
Institution which also involve the training for industrial student is known to be under
the authority of the Ministry of Human Resource which is a separate entity from the
Ministry of Higher Education that may give the gray area in the SOP implementation
(Institution, 2021). Thus, no official Standard Operational Procedure (SOP) or
guideline has been provided for used in reducing the risk of Covid-19 infection. In
addition, an opening of education sector institutions has proven to exponentially
raise the risk of Covid-19 transmission (Sebastiani and Palù, 2020). Thus, this study
will address the outbreak response and the importance of gatekeeping in preventing
the occurrence of the Covid-19 outbreak.

METHODOLOGY

This study is a descriptive study using secondary data based on an occurrence of
Covid-19 outbreak at Training Institution in Kubang Pasu, Kedah from 1st of
November 2021 until 26th December 2021. The area of the institute is approximately
12 hectares, which is residence by 541 hostel students age of 18 to 24 years old
during the outbreak. There were 5 hostel block available for student, where only 3
warden located to monitor the student activity

On 9th November 2021, a symptomatic self saliva testing from 1 student result a
positive result. Subsequently Polymerase Chain Reaction (Rt-PCR) used and
confirmed the positive result. The case label as an index case proceeded with further
investigation.

A formal outbreak investigation started upon multiple cases of Covid-19 confirmed
case with epid link reported from a Training Institution in Kubang Pasu. Active and
passive contact tracing subsequently takes place for at least 2 incubation periods
(IP) from the last reported confirmed case. Data from outbreak line listing involving
the institution extracted anonymously and analyse descriptively using Microsoft
excel. The variable extracted from the line listing included date of positive, age,
hostel block, gender, symptom status, vaccine status, type of screening, and type of
diagnostic test.

111

RESULTS
From 541 students who stay in Hostel, 113 students have been identified as close
contact. Among 113 hostel students from contact tracing and testing, 34 has been
laboratory confirmed positive. Table 1 shows the sociodemographic characteristics
of Covid-19 confirmed cases.

Table 1: Sociodemographic characteristics of Covid-19 cases (N=34)

Variable n (%)

Age (Years)

18 13 (38.23)

19 9 (26.47)

20 8 (23.53)

21 3 (8.82)

24 1 (2.94)

Gender

Male 34,(100)

Hostel Block

E 30,(88.24)

D 4,(9.76)

Symptom status

Symptomatic 23,(67.65)

Asymptomatic 11,(32.35)

Vaccine Status

Complete 34,(100)

Type of Case detection

Active case detection 24 (70.58)

Passive case detection 10 (29.41)

Diagnostic test

Polymerase Chain Reaction (RT 30 (88.24)

PCR)

RTK-Ag 4 (9.76)

Only 4 samples were positive on 2nd sample. There is no involvement of positive
cases from female hostel despite 2 female students from contact tracing tested.
Majority of cases are symptomatic with the dominant symptom are fever cough and
runny nose. As all cases are fully vaccinated, it may contributed to the reason why
all cases were only categorized as category 1 and 2 and discharged well after
quarantine for 7 days at quarantine center without hospital admission. Only 10 cases
from total of cases obtained from passive case detection which mean during the
initial screening. Subsequently contact tracing reveal another additional of 24 cases

112

Figure 1: Epidemic Curve of Training Institution Covid-19 Outbreak in Kubang
Pasu

The epidemic curve demonstrates the chronology of cases and the relevant event
started from the student entry until the outbreak declared and the intervention steps
taken in mitigating the spreading of infection. The propagated trend of the epidemic
curve is synonym with an infectious disease that is transmitted from individual to
individual which is relevant in current study. From investigation, entry of student only
require verbally informed the saliva test result before entry as the only screening
criteria implemented by the training institution administrative. Besides, after the
student entry in early November 2021, students are still allowed to go home on a
public holiday (Deepavali & weekend) without a compulsory quarantine for at least
7 days as recommended since all students are vaccinated (CDC, 2021b). With the
earliest onset on the 3rd of November, loose screening criteria and no quarantine
period may cause a high risk of infection among students. Throughout the outbreak,
3 legal notices using Prevention and Control Communicable Disease Act 1988 have
been released by Kubang Pasu Health District Office including instruction for strictly
on SOP among students and not allowing any external visitor to control the outbreak
(Malaysia, 1988). The outbreak contained with monitoring for 4 weeks (2 IP) after
the last case and there was no new case reported.

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DISCUSSIONS
In preventing and containing the Covid-19 outbreak, generally, the occupational
hierarchy of control framework can be adopted as a guide including engineering,
administration, education, and personal protective equipment since elimination and
substitution are not possible to be used in infectious disease (Bonell et al., 2020).
The framework can be applied in strengthening or guiding the process of
gatekeeping at any institution especially involving students sharing the same
environment area including physically attended class, hostel, religion building, and
Caffe.

From Table 1, the showing only male student are potential tow(aMrdOtHh,e2r0is2k1bo)f being
infected by Covid-19 infection. This may be contributed to low adherence toward
SOP among those student especially when involving hostel environment. With
dominantly symptom of fever, cough and runny nose the risk of disease spreading
increase.

Starting with the process of student intake, a staggering batch of intake may reduce
the crowd and reduce the risk of infection (UNICEF, 2020). Staggering based on
batch or relevant course may be appropriate. However, from this current study, most
of the course requires a physically attended class since the training center involve
the usage of practical and workshop. Thus, staggering may cause disturbance of
syllabus. Hence some alterations of the syllabus like shifting, rescheduling class, or
reorganizing class at more open places to ensure no crowding at the same time and
place.

Ensuring complete vaccination at least 2 doses among individuals does provide a
certain degree of protection from spreading the Covid-19 or getting infected with
Covid-19 from others (Eyre et al., 2022). This criteria for allowing student admission

114

as been practiced by the Training Institution administrative may reduce the risk of
disease transmission. However, consideration of the waning effect should be of
concern in view of the evidence of antibody reduction over time (Eyre et al., 2022).
Thus, individuals are encouraged for a booster dose to enhance their immunity.
However, since the vaccine introduction is still new, the long-term response related
to vaccination has still been unknown (Scott et al., 2021).

As recommended, eventhough fully vaccinated, there should be a universal masking
indoor at substantial or high community transmission especially when sharing a dorm
(CDC, 2021b). Descriptively analysis of current outbreak show that majority infection
in this study involving student in Block E which about 88% of total infection. This may
result of sharing same environment that may cause spreading of infection easier due
challenge in enforcement of strictly SOP especially when involving wearing face
mask. Scheduled or staggered timing for meal time may be appropriate to reduce
physical contact and crowding that increase the risk of infection.

A current data suggest that the risk of Covid19 transmission is minimal in outdoor
setting (CDC, 2021b). The ventilation playing a role in disease transmission
especially if the disease involving airborne or droplets spread . Thus, a measures
should be taken to reduce the impact of the environment on transmission rate
variation that may contribute to lower the risk of occurrence of outbreak. Indoor,
crowded, noisy, poorly ventilated venues with singing, eating, and dining are known
to pose a significant risk (Tupper et al., 2020). The minimum safe distance
recommended to mitigate the risk of infection can be range from 1.6m-3m apart for
normal activity like breathing activity and it can get maximum up to 8.2m distance to
further reduce the risk of infection lower as only 5% (Sun and Zhai, 2020). Although
physical distance reduces the risk of infection, lowering the Pollution Index (PI) to a
lower level (for example, 2%) necessitates sufficient ventilation to dilute pollutants
from infectors (Sun and Zhai, 2020).Lowering the PI need a better ventilation rate
which need a spacious area. Alternatively, by reducing the occupancy up to 50%
may effectively reduce the infection risk if with similar ventilation and exposure time
period (Sun and Zhai, 2020). This fact may be usefull in keeping the safe distance
or environment among student either in hostel or in common space.

An accurate & standardized criteria for testing before student entry is compulsory
not just to mitigate an outbreak, in fact, it can prevent the disease transmission.
They’re known to have 2 methods appropriate on testing framework which are i)
testing upon detection or symptomatic and ii) regular testing for any individual
regardless of symptom (Tupper and Colijn, 2021). The later is a more appropriate
method in preventing the outbreak as the Covid-19 patient may not all present with

115

symptom (Lavezzo et al., 2020). Recommended test for Covid-19 confirmatory is
RT-PCR while RTK maybe use as an alternative if the prevalence is more than 10%
of the population having the Covid-19 infection (MOH, 2021a). This test can be done
2-3 days prior to the day of institution entry to ensure no entry of infection. Even
though, a correct method on how the test been delivered may need adequately
supervised by a qualified personel. As this study discovered that only require a
verbal swab report with unsupervised testing before allowing to enter the hostel, the
risk of misinterpret of result or false negative may be high. These situations further
elevate the risk of infection among students.

One of the oldest and most successful techniques for managing infectious illness
epidemics is quarantine. Quarantine means that persons who are suspected of
having been exposed to a contagious illness but are not unwell, either because they
did not get infected or because they are still in the incubation phase, are restricted
from moving (Wilder-Smith and Freedman, 2020). Upon entry to the institution, the
recommended for quarantine should be at least 7 days for fully vaccinated
individuals and 10 days for unvaccinated since the incubation period for Covid-19 is
ranges about 2-14 days (MOH, 2021b). Looking from the epidemiological curve of
these study, as the 1st onset of symptom on 3rd November, however the student was
allowed to go physical attended class, going home/outing during Deepavali (4th - 6th
November) and weekend (12th – 13th November) without compulsory quarantine
within Covid-19 incubation period. This may result Covid-19 transmission among
students easily.This study had several limitations since its used secondary data
which is from the outbreak line listing. No data verification can be done. However,
this study manage to identify the possible event that related to the risk of the outbreak
occurrence which related to the gatekeeping process.

CONCLUSION

Gatescreening and adherence toward SOP are the key point in preventing or
reducing the risk of infection among students in institution. The gatescreening
including ensuring vaccination, early screening, and monitoring may significantly
reduce the risk of communicable disease transmission including Covid-19.
Meanwhile, adherence to SOP like wearing face mask, physical distancing may
further reduce the risk of disease transmission. Ensuring the quality of gatescreening
and adherence toward SOP up to the standard is crucial involving dissemination of
a standard guideline may achieve the objective. Allocating a qualified or trained
individual for a good gatekeeping may be appropriate

116

ACKNOWLEDGEMENT
The authors would like to thank the Director General of Health Malaysia for his
permission to publish this paper. I would like to express my gratitude to Kedah Health
Director and Kubang Pasu Health District Officer for authorization to release the data
and also Investigating Officer of Kubang Pasu Health District involved in preparing
the Covid-19 Outbreak line listing for analysis.

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RAPID CONTAINMENT OF COVID-19 OUTBREAK- LEARNING
EXPERIENCE FROM OUTBREAK MANAGEMENT IN HIGHER

EDUCATION INSTITUTIONS IN PADANG TERAP.

Muhamad Fadhil M.M., Muhammad Omar M.Y, Musa M.M, Dhinagar S.R

Padang Terap District Health Office
*Corresponding author: Dr Muhamad Fadhil bin Mohamad Marzuki, [email protected]

ABSTRACT

Background: As an emerging infectious disease, COVID-19 has involved many
countries and regions. With the further development of the epidemic, the proportion
of clusters has increased. Rapid containment is the key to control the cluster of
COVID-19 in the high-risk community such as higher educational institution or
college.

Methodology: For our study, we gathered data from COVID-19 clusters that
occurred in a college in Padang Terap, Kedah. The epidemiological characteristics
as well as clinical manifestations were described.

Results: One cluster of COVID-19 was reported in Padang Terap, Kedah on
January 8, 2021, in a college here. There were 11 confirmed cases, 41 suspected
cases, and 13 close contacts, accounting for 17.1% of all exposed students. Patients
aged 18–19 years old and all of them are male students. Many patients exhibit
symptoms that started on the 2nd to 11th of January 2021. No more cases detected
beyond 11th January 2021 after rapid containment action involving active case
detection, isolation of all confirmed cases to the hospital or Pusat Kuarantin dan
Rawatan Covid-19 (PKRC) and quarantine of all suspected cases and their close
contact. Effective risk communication to all stakeholders including the worried parent
at home has ensured that all the control measures can be executed successfully.

Conclusion: Effective communication has created good collaboration between PKD
Padang Terap and the college management, leading to the successful
implementation of all control measures and rapidly controlled the outbreak.

Keyword: cluster, COVID-19, epidemiology, effective communication

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INTRODUCTION
In December 2019, several cases of pneumonia of unknown aetiology and not
caused by any known respiratory virus infection were reported in Wuhan, Hubei
province, China [1]. On February 11, 2020, this new infectious disease was officially
named "COVID-19" by the World Health Organization (WHO) (WHO, 2020). Given
the global challenges to public health attributed to the SARS-CoV-2 outbreak in
China, the WHO has declared the SARS-CoV-2 as a public health emergency of
international concern.

Patients with COVID-19 infections are the main source of infection, and
asymptomatic carriers are also infectious to other healthy people. As SARS-CoV2
virus is a novel virus, people are generally susceptible to be infected mostly by
means of droplets or direct contact (Bulut & Kato, 2020). Back in May 2020 when
Malaysia is facing with increasing trend of COVID-19 cases with daily reported case
nearly 7000 cases, Ministry of Health Malaysia (MOH) has come out with many
recommendations to break the chain of SARS-CoV2 transmission (DG of Health,
2020). Among them are to avoid 3C which are close space, crowded place and
closed conversation.

There are numerous institutions in Malaysia, and if not handled correctly and quickly,
they pose a risk of COVID-19 outbreak. Some areas in our higher education
institutions are very high-risk for SARS-CoV2 transmission for example the student
residential block (CDC, 2022). Students stay in a twin sharing room up to dormitories
that accommodated up to 18 to 20 students. The residential block usually does not
have ensuite bathroom and students have to share bathroom with 20 to 30 other
students. There are also other common areas such as television room, ironing room,
and pantry. These are the critical point whereby the infection can spread among
student and create a COVID-19 cluster in institution.

On January 8, 2021, a phone call was received from a fellow of the college, informing
that one of their student parents were positive after being tested for COVID-19 in KL.
The student who just arrived at the college a few days ago also down with cough
and a sore throat. The student was brought to Kuala Nerang Hospital and tested
positive; thus, outbreak control measures was conducted immediately. In this paper,
we are sharing the epidemiology of a COVID-19 cluster that occur in one of the
colleges in the district of Padang Terap and our experience in handling the cluster
rapidly and successfully.

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METHODOLOGY

Sources of data
Case data was collected from a static clinic set up at the outbreak site. They
conducted interviews and collected test samples that fulfilled clinical and
epidemiological requirements (Hyland-Wood et.el, 2021). All data was collected and
managed by the Crisis Preparedness and Response Centre (CPRC) Padang Terap
District Office.

Case Definitions

Suspected case : Students and staff who have symptoms of fever (T> 38oC) or
cough or sore throat or runny nose since 2/1/2021 (Date of first
reporting to college).

Confirmed case : Students and staff who have symptoms of fever (T> 38oC) or
cough or sore throat or runny nose since 2/1/2021 (Date of first
reporting to college) and confirmed positive for COVID-19
infection.

Close contact : Students and staff who are assymptomatic, but be in a closed
space for more than 15 minutes, are at a distance of less than 1
meter, or live in a room with a positive case.

Data Collection Methods
1. Face to face Interview Method: All cases and exposed students and staff were
interviewed to obtain travel history, and symptoms experienced.

2. Walk through survey and situational analysis in the college’s area involving
both residential and academic block.

3. Laboratory Test: 20 throat swab samples were taken and sent to Ipoh Public
Health Laboratory. Samples of Viruses (RT-PCR) (10) and Bacteria
(Culture&Sensitivity Test) (10).

Statistical Analysis

Data were analysed using Microsoft excel.

Attack Rate was calculated based on the formula:

Attack Rate = Number of patients x100

Number of exposed students

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RESULTS
A cluster was declared this college on 8/11/2021 after several cases tested positive
for SARS-CoV2. There were 380 students and staff that were exposed (Table 1).
The students have just come back to the college for their examination week. There
were face to face classes, study groups, and small group discussion during that
period therefore, all student and staff were considered exposed.

Table 1: Population at risk by Sex and Categories (n=380).

Populations Male Female Total,
N
n (%) n (%)
347
Students 193 (55.3) 154 (44.7) 33
Staff 10 (30.3) 23 (69.7) 380
Total 203 (53.4) 177 (46.6)

The active case detection was conducted by a mobile medic team from Padang
Terap District Health Office via a static clinic that ran daily for two weeks. A total of
11 confirmed cases were identified and isolated in the PKRC and hospital, making
an attack rate of 17.1%. There were 54 students felt into case definition of suspected
case and close contacts that were traced and quarantined in the quarantine block in
that college itself. They were monitored daily by the mobile medic team. Table 2
showed the distribution of students that fulfilled the case definition.

Table 2: Distribution by case definition.

Male Female Total,
n (%) N
n (%) 0 (0) 11

Confirmed 11 (100)

Suspected 26 (63.4) 15 (36.6) 41

Close Contact 5 (38.5) 8 (61.5) 13

Total 42 23 65

Attack Rate: 65/280 x 100 = 17.1%
All 11 positive cases were male students. The prominent symptoms experienced by
all 65 students (confirmed case, suspected case, and closed contact) are sore throat
followed by runny nose, cough and fever. Figure 1 shows the distribution of
symptoms experienced.

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Yes No

100% 25
90% 33
80%
70% 44
60% 50
50%
40% 40
30% 32
20%
10% 21
0% 15

Sore Throat Runny Nose Cough Fever

Figure 1: Distribution of Symptoms experienced by cases.

All ten out of 20 sample of naso-oropharyngeal swab (NSO) taken confirmed the
infection of COVID-19. Sample virology and bacteriology showed negative results
(Table 3).

Table 3: Result of Clinical Sample taken

NSO Swab Virology Bacteriology Total

PCD 11 (positive) - 11
ACD 10 (negative) 10 (negative) 20
Total 31
21 10

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The student’s residential complex consists of 5 blocks, 2 blocks and 1 block for male
and female respectively. Another two blocks are empty as the enrolment of students
was reduced to 70% due to COVID-19 pandemic. All 11 confirmed cases were
mapped according to their room number. Nine out of 11 cases stayed in the Level 1
Block R. Figure 2 showed the mapping of the nine cases according to their room.
The other two cases have no epidemiological link to these nine cases and believed
they were infected before returning to the college.

121 119 117 115
Case 2 Case 3
Case 10 Case 4
Toilet
Entranc

e

120 118 116 114
Case 8 Case 7 Case 5

Case 9 Case 6

Figure 2: Mapping of the nine cases according to their room.

After 2 two weeks of containment period, and 28 days of surveillance phase, there
was no new case emerged from the students as well as the staff. Figure 3 showed
the epidemiology curve of these cluster.

3

Number of Cases 2

1

0

Dates of onset

Figure 3: The epidemiology Curve based on the Date of Onset of Symptoms.
28.12
29.12
30.12
31.12

1.1
2.1
3.1
4.1
5.1
6.1
7.1
8.1
9.1
10.1
11.1
12.1
13.1
14.1
15.1
16.1
17.1
18.1
19.1
20.1

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A walk-through survey and situational analysis conducted found that the
incompliance with the standard operating procedure and malpractice of the new
norm have triggered the chain of transmission among the students. Nine of the cases
may have been infected when they studied together in a group in their hostel room.
They not using face mask, study together in closed space, crowd place, and have
closed conversation for a long time. The practice of new norm such as wearing face
mask, physical distancing, disinfection of frequently touched surfaces such as door
knobs, and ineffective hand washing also contribute to the spread of the disease.
The poor lightning and ventilation in the hostel and less monitoring of the sick
students also made the viruses viable longer in the environment thus increasing
chances to infect other students.

Padang Terap District Health Office has worked closely with the college
management to execute rapid control measures and successfully control the spread
of covid-19 disease in the college. Among the actions that have been taken were:

1. Active Case Detection (ACD)
Carrying out Active Case Detection by the mobile medic team. The static clinic is
open daily from 9am to 3pm in the parking area near the residential block. ACD is
very important to detect, isolate and treat the student as fast as possible before they
can spread the infection to their friends.

2. Monitoring of SOP
Monitoring of SOPs with college’s representatives was also done at the residential
and academic blocks. The findings were discussed during a daily briefing with the
college’s management team. Wearing mask, maintain the physical distant, practice
good hand hygiene, and avoid overcrowding in a closed space are among the SOP
that have been emphasized. Student representatives also were empowered to self-
monitor the student especially at the residential area. With the good compliance to
the SOPs, the risk of transmission can be reduced further.

3. Targeted Movement Control Order (TMCO)
Targeted movement control order throughout the control period. All quarantine
students stayed in the room except to the toilet, meals were sent to the entrance of
every level in the quarantine block. Academic block, surau and shared facilities are
completely closed. Learning session were conducted via online. This action was
continued for 2 weeks. The number of cases reduce tremendously after 1 week of
TMCO.

125

4. Health education
Health education sessions on new norms practice and SOP compliance for staff and
students were conducted. The sessions were held after all close contacts and
students with symptoms were identified and isolated emphasized on the importance
of adopting new norms to prevent the transmission of COVID-19 infection. Banners
and streamers also were hung at the strategic places.

5. Risk Communication.
Engagement sessions are conducted with the college’s management team on daily
basis whereby case findings, control measures to be taken and any issues raised
during the execution of control activity were discussed. Risk communication is very
important to calm the situation and gain a good cooperation from the college
management, and students. Every single action taken was discussed and explain to
all stakeholders so that they understood and able to follow them efficiently. With a
good risk communication also, the worrying parent can be calm down and give a full
support to the outbreak managing team. A virtual meeting session with parent
association also was carried out to provide a real situation and explain the control
measures that have been and will be taken. This has alleviated the concerns of the
parent.

6. College Disaster Committee and staff empowerment program.
Establishment of college disaster committee and staff empowerment program in
which the sanitation activities are carried out by staff under supervision of the BAKAS
unit. The sanitation activities is very important especially at the common area and
frequently touched surfaces to prevent the spread of the viruses. Therefore, the team
was trained and supervised closely during the outbreak so that they can carried out
an effective sanitation activity even after the outbreak end.

DISCUSSIONS

On the 8th of January 2021, Crisis Preparedness Response Centre, Padang Terap
District Health Office received a call from one of the higher educational institutions
in Padang Terap informing that one of the student’s parents from Kuala Lumpur had
been tested positive for SARS-CoV2 virus. During that time, all students had just
come back to the college to sit for their exam. A rapid assessment team (RAT) was
dispatched to the college to investigate the situation. Once the outbreak confirmed,
a rapid response team (RRT) was gathered and a command centre lead by a public
health physician was opened. Preparation to execute control measures were done
immediately with an assumption that this might be the beginning of the Covid-19
outbreak and not to wait for more information (CDC, 2016). It is important not to wait
for longer time as finding from RAT showed that the risk of outbreak occur in

126

residential block is very high (Bao et al., 2021; Kuebart & Stabler, 2020; Kumar &
Morawska, 2019).

A total of 11 confirmed cases, 41 suspected cases and 13 asymptomatic close
contact were detected via static clinic run by medic team from PKD Padang Terap.
All confirmed cases were sent to either hospital or PKRC and the rest were
quarantine the quarantine block that was prepared by the college under supervision
of PKD Padang Terap. They were monitored closely by the medic team. Isolation
and quarantine is very important to break the chain of infection and prevent further
transmission to other student (Cardwell et al., 2022; Fan et al., 2021; Sehgal,
Himmelstein, & Woolhandler, 2021).

Risk assessment done by a team of health inspectors noted the student there had
poor compliance with SOPs, the tight and cramped space in the common and study
rooms, the poor compliance on wearing of masks, not maintaining physical distances
during study and unsatisfactory hand hygiene are believed to be contributing to the
spread of the virus. Ministry of Health Malaysia (MOH) has frequently advice the
public to adhere with the SOP and new norm practices such as wearing face mask,
frequent hand washing, keep a safe physical distant, and avoid crowded place,
closed space and closed conversation (Ganasegeran, Ch'ng, & Looi, 2020). At this
time the vaccination program still hasn’t started thus the most effective measure to
reduce spread of covid-19 was to follow SOP that is wearing mask, physical
distancing and practicing good hand hygiene. Moreover, our country has imposed
stick penalty for not wearing mask, many have argued the need to wearing mask but
based on study conducted showed that cotton masks, surgical masks, and N95
masks had a protective effect with respect to the transmission of infective
droplets/aerosols and that the protective efficiency was higher when masks were
worn by the virus spreader (NST, 2020; Ueki et al., 2020).

The college management also do not have a proper SOP to accept students that are
coming back especially from redzone. The first case tested positive was originated
from Kuala Lumpur whereby Kuala Lumpur during that time was a redzone with daily
cases reaching 3 digits. A gate screening was conducted based on the body
temperature scanning and self-declared of Covid-19 symptoms followed by weeks
of quarantine in residential block. However, the students were mixed up without risk
assessment and they do not adhere with the quarantine order. The incubation period
for SARS-CoV2 virus is 14 days. On average, symptoms showed up in the newly
infected person about 5.6 days after contact. Rarely, symptoms appeared as soon
as 2 days after exposure. Most people with symptoms had them by day 12. And
most of the other ill people were sick by day 14. In rare cases, symptoms can show

127

up after 14 days (WebMD, 2021). Students may come back to college during
incubation period therefore the gate keeping was unable to screen those
symptomatic.

Mapping of all cases also showed that nine out of 11 cases stay in the same level
especially when they shared the same room or command area without any personal
protective equipment (Ge et al., 2021; Liu et al., 2020). Only two students were put
in one room. However, as they were preparing for their exam, the nine students sit
together in same room for their study group. Failure to keep the safe physical
distancing and not wearing mask has allowed the chain of transmission to occur.

Effective communication has played a very important role in managing this outbreak
(Hyland-Wood, Gardner, Leask, & Ecker, 2021). Every finding from the ongoing
assessment and analysis of the situation were discuss with the college management
during the daily briefing. Good collaboration with the stakeholders is very important
to get their cooperation in executing the control measures. We also took this
opportunity to document all control measures, the issue raised, and best practice to
manage such situation in the future. The college management manage to come out
with the standard operating procedure that will be used as a guidance later on.
Understanding and practicing various communication strategies is crucial for health
officer and team to develop therapeutic relationships with COVID-19 patients as well
as their family. Addressing psychology in all people is vital during a pandemic and
effective communication network is key to it (Reddy & Gupta, 2020). Effective
communication, if ignored, will generate gaps for vulnerable populations and result
in added difficulty in combating COVID-19 pandemic. As part of risk communication
to alleviate the concern by the parent, an online session with them also was
conducted organized by the parent association.

CONCLUSION

A cluster of Covid-19 that occurred in a college has been successfully managed.
There were no new cases after all control measures were executed. Poor adherence
to the quarantine order, and malpractice of new norm among students that have just
come back to college including those from high-risk areas has created a nightmare
of Covid-19 outbreak in their college. Effective communication has created the good
collaboration between PKD Padang Terap and the college management leading to
the successful implementation of all control measures and rapidly controlling the
outbreak.

128

ACKNOWLEDGEMENT

The authors would like to thank the Director General of Health Malaysia for his
permission to publish this paper. We would like to thank the college management
who give the full cooperation during the outbreak of Covid-19 in their college. We
also would like to thank the medial and health team from Padang Terap District
Health Office who work very hard in ensuring the all the control measures were
executed successfully.

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130

PENULARAN COVID-19 DI SEBUAH INSTITUSI PENGAJIAN,
KLUSTER DEDAP: KEPENTINGAN ASPEK PEMATUHAN AMALAN

NORMA BAHARU DI INSTITUSI PENGAJIAN

Dr Shahrul Izzat Bin Mat Akhir1, Dr Suriani Binti Noor Azam1, Nornatrah Binti
Omar1, Muhammad Shahidan Bin Abu Bakar1, Dr Siti Rohana Binti Ahmad1

1Pejabat Kesihatan Daerah Yan, 08800 Guar Chempedak, Kedah

__________________________________________________________________

ABSTRAK

Latarbelakang: Virus COVID-19 adalah sejenis virus yang boleh menyebabkan
jangkitan saluran pernafasan yang mula dikesan pada akhir tahun 2019. Terdapat
beberapa SOP yang telah ditetapkan oleh pihak Majlis Keselamatan Negara dan
Kementerian Kesihatan Malaysia bagi mengekang penularan virus ini. Institusi
pengajian sudah tentu tidak terlepas dari penularan COVID-19 ini. Objektif kajian
adalah bagi menerangkan punca jangkitan dan faktor yang menyumbang kepada
berlakunya penularan di institusi ini dari sudut sosiodemografi, presentasi klinikal
dan faktor persekitaran.

Kaedah Kajian: Kajian ini merupakan kajian rentas yang menggunakan rekod-
rekod yang diperolehi semasa berlakunya kluster. Kaedah penyiasatan adalah
melibatkan penyiasatan epidemiologi, makmal dan pemeriksaan persekitaran.
Maklumat diperolehi daripada rekod-rekod pesakit, melalui temuramah, dan
pemerhatian terhadap pematuhan SOP. Data telah di analisa menggunakan
perincian Microsoft Excel.

Hasil kajian: Sejumlah 71 kes adalah terdiri daripada pelajar lelaki dengan kadar
serangan sebanyak 33% (71 daripada 215 penghuni) manakala 47% daripada
penghuni mempunyai gejala. Keluk epid menunjukkan onset gejala yang pertama
adalah pada 28/1/2021. Faktor risiko penularan yang dikenal pasti adalah
disebabkan ruang bilik yang sempit dan padat dan ketidakpatuhan terhadap SOP
yang ditetapkan.

Kesimpulan: Pendidikan kesihatan mengenai kepentingan pematuhan kepada
SOP yang berterusan dan juga pembudayaan amalan norma baharu harus lah
diterapkan ke dalam gaya hidup para pelajar, guru-guru dan warga sekolah secara
amnya.

Kata Kunci: Covid-19, institusi pengajian, kluster dedap, SOP

131

PENGENALAN

Coronavirus (CoV) adalah sejenis virus yang boleh menyebabkan jangkitan saluran
pernafasan kepada manusia. Terdapat beberapa jenis spesis coronavirus yang
telah di kenalpasti antaranya adalah Severe Acute Respiratory Syndrome
Coronavirus (SARS) dan Middle East Respiratory Syndrome-related coronavirus
(MERS-CoV). Terkini, spesis coronavirus terbaru yang telah ditemui di China adalah
Coronavirus 2019 yang dikenali dengan nama Covid-19 (KKM, n.d). Pada masa
yang singkat sahaja spesis ini telah tular ke seluruh dunia dan memberikan cabaran
yang besar terhadap aktiviti kawalan penyakit, sosial dan ekonomi. Sehingga kini,
Covid-19 terus menjadi perhatian dunia di atas penularannya yang cepat dan
meluas (Ivan, 2020). Di Malaysia, Kementerian Kesihatan Malaysia (KKM) telah
mengeluarkan garis panduan norma baharu yang merupakan Standard Operating
Procedure (SOP) dalam aktiviti seharian bagi mengekang penularan virus ini dalam
masyarakat. SOP ini di buat adalah bertepatan dengan saranan daripada
Pertubuhan Kesihatan Sedunia (WHO) dengan menekankan prinsip-prinsip
kesihatan awam sebagai langkah kawalan penularan jangkitan.

Daerah Yan merupakan salah satu daerah dalam negeri Kedah yang mempunyai 5
mukim termasuklah mukim Sala Besar, Yan, Sg Daun, Dulang dan Singkir. Terdapat
beberapa buah institusi pengajian awam dan swasta yang beroperasi dalam daerah
ini. Pada 11 Februari 2021, satu kluster Covid-19 melibatkan sebuah maahad tahfiz
yang terletak di Kampung Sg Dedap telah diisytiharkan oleh Kementerian Kesihatan
Malaysia. Kluster ini telah di beri nama sebagai Kluster Dedap berdasarkan nama
lokaliti berlakunya kluster. Ianya mula dikesan apabila terdapat pelajar yang telah
disahkan positif Covid-19 melalui saringan bergejala. Kluster ini telah berjaya di
kawal dan diisytiharkan tamat pada 17 Mac 2021.

Maahad Tahfiz ini dikenali sebagai Maahad Tahfiz As-Syatirie Sg Dedap, dibina
pada 30 Januari 2009 dan merupakan sekolah pondok persendirian yang berdaftar
dibawah Jabatan Agama Islam Negeri Kedah. Pada tahun 2021, terdapat sejumlah
215 orang penghuni yang terdiri daripada pelajar, pekerja sokongan dan juga guru
– guru bersama ahli keluarga. Lokasi maahad ini terletak kira – kira 18 kilometer
(km) daripada Pejabat Kesihatan Daerah Yan dan 14 km daripada Hospital Yan dan
kawasan persekitaran adalah dikelilingi oleh sawah padi. Sistem pengajian Maahad
tahfiz ini adalah berasaskan pembelajaran kitab-kitab agama. Pembahagian kelas
adalah berdasarkan pembelajaran sesuatu kitab untuk satu-satu masa. Pelajar
belajar secara bersemuka dengan pengajar di pelbagai tempat di kawasan sekolah
termasuklah di surau.

132

Kes pertama di maahad ini dikesan apabila salah seorang daripada pelajarnya
mendapatkan rawatan di Hospital Yan kerana mengalami beberapa gejala seperti
demam, batuk berkahak, sakit kepala, hilang deria bau dan deria rasa.
Walaubagaimanapun, pelajar tersebut tiada rekod sejarah perjalanan ke kawasan
zon merah ataupun mempunyai hubungan kontak rapat dengan mana-mana kes
positif. Ujian saringan Covid-19 dijalankan dan kes ini dibenarkan pulang dan
menjalankan kuanrantin kendiri di asrama maahad.

Sebaik sahaja mendapat notifikasi keputusan ujian Covid-19 daripada Hospital Yan,
satu senarai pengenalpastian (linelisting) diperolehi dan pengasingan untuk pelajar
yang bergejala dan tidak bergejala dijalankan. Arahan kuarantin (Home Surveillance
Order – HSO) dikeluarkan pada 8 Februari 2021 dan pelajar yang dikenalpasti
sebagai kontak rapat (close contact) dan kontak potensi (potential contact)
digelangkan serta kerja-kerja disinfeksi kuman dilakukan diseluruh kawasan
Maahad Tahfiz. Maahad ini diarahkan tutup sementara dibawah Akta Kawalan
Penyakit Berjangkit 1988 pada 9 Februari 2021. Satu mesyuarat bencana telah di
lakukan di peringkat daerah dengan penglibatan agensi-agensi kerajaan dan telah
di pengerusikan oleh Pegawai Daerah Yan bagi membincangkan aspek-aspek
kawalan keselamatan dan kebajikan penghuni yang dikuarantin di maahad tersebut.
Kegiatan keluar masuk dari kawasan maahad dikawal ketat oleh pihak polis dengan
kerjasama pihak RELA. Sepanjang tempoh kuarantin dikenakan di maahad ini, tiada
Perintah Kawalan Pergerakkan Diperketat (PKPD) dikeluarkan bagi Kluster Dedap
ini.

KAEDAH KAJIAN

Kajian ini adalah kajian deskriptif dan secara kaedah kajian keratan rentas yang
menggunakan rekod-rekod yang diperolehi semasa kejadian Kluster Dedap yang
bermula dari 11 Februari 2021 sehingga 17 Mac 2021. Analisa data-data
kemudiannya dilakukan dengan bantuan perisian Microsoft Excel. Terdapat 3 aspek
dalam penyiasatan iaitu penyiasatan epidemiologi, penyiasatan makmal dan
pemeriksaan persekitaran termasuk pematuhan SOP dan keadaan tempat tidur dan
penginapan pelajar-pelajar. Penyiasatan epidemiologi yang dilakukan adalah
merupakan temuduga semua penghuni Maahad tersebut yang terdiri daripada
pelajar, guru dan tukang masak. Pasukan RAT (Rapid Assessment Team) telah
turun dan melakukan aktiviti pengesanan kes secara aktif (active case detection).
Data-data demografik didapatkan dan direkodkan seperti umur, jantina, status
gejala, onset gejala, jenis gejala dan nama bilik untuk tujuan statistik dan analisa.

133

Semua penghuni Maahad adalah dikategorikan sebagai kontak rapat
(termasuk ‘close’ dan ‘potential’) atau penghuni yang terdedah. Pada awalnya,
pemilihan sampel dibuat hanya kepada yang bergejala dan mempunyai risiko tinggi
seperti mempunyai penyakit kronik. Tetapi memandangkan keadaan Maahad yang
berisiko tinggi dalam penularan virus seperti keadaan yang rapat dan sempit dengan
bilangan penghuni yang ramai dan juga faktor ketidakpatuhan SOP dikalangan
pelajar-pelajar, sampel diambil untuk semua pelajar. Keputusan ini dibuat beberapa
hari selepas pemantauan terhadap pelajar-pelajar yang dikhuatiri penularan tidak
dapat dibendung dengan baik dan mengambil kira kebimbangan terhadap kesihatan
penghuni-penghuni Maahad tersebut. Penyiasatan makmal dilakukan dengan
mengambil sampel PCR.

Definasi kes ‘confirmed case’ adalah semua kes yang didapati positif PCR.
Ujian RTK juga dilakukan untuk tujuan kawalan kerana keputusan adalah lebih cepat
iaitu dalam masa 3-4 jam. Keputusan PCR pula mengambil masa 1 – 2 hari.
Berdasarkan keputusan ujian RTK – Penghuni-penghuni dapat diasingkan diantara
yang positif dan negatif, juga selepas itu kepada yang bergejala dan tidak bergejala,
untuk membendung penularan jangkitan. Pemeriksaan persekitaran yang dilakukan
adalah pemeriksaan tempat penginapan pelajar-pelajar seperti tempat tidur, bilik air
dan tandas, tempat makan dan tempat belajar. Penilaian dibuat berdasarkan
pemerhatian merangkumi aspek pengudaraan, pencahayaan dan keluasan bilik.
Siasatan mendalam mengenai aktiviti harian pelajar juga dilakukan untuk menilai
aspek pematuhan SOP dan norma baharu.

HASIL KAJIAN

Jumlah keseluruhan penghuni mahaad ini adalah seramai 215 orang dan
kesemuanya adalah terdedah terhadap risiko jangkitan. Sebanyak 71 kes positif
telah di kesan menjadikan kadar serangan adalah 33%. Penghuni yang bergejala
(positif atau negatif) adalah seramai 47.4%. Jadual 1 menunjukkan data-data
sosiodemografi penghuni dan jadual 2 menunjukkan maklumat yang lebih terperinci
mengenai pekerjaan penghuni-penghuni berdasarkan jantina. Seramai 202 (95%)
dari jumlah terdedah terdiri daripada pelajar. Hanya 11 (5%) orang terdiri dari guru
dan 2 (0.9%) orang tukang masak. Lelaki adalah seramai 203 (94.4%) orang iaitu
majoriti dan hanya 12 (5.6%) perempuan yang merangkumi pelajar, guru dan tukang
masak.

134

Jadual 1: Sosiodemografi penghuni maahad dan ciri-ciri klinikal (N=215)

Sosiodemografi Bilangan (n) Peratus (%)

Umur (tahun) 123 57.2
17 tahun dan kebawah 85 39.5
18-29
30-39 5 2.3
40-49 1 0.5
50-59 1 0.5

Jantina 203 94.4
Lelaki 12 5.6
Perempuan
213 99.0
Kaum 1 0.5
Melayu 1 0.5
Arab
Indonesia 202 94.0
11 5.1
Pekerjaan 2 0.9
Pelajar
Guru 102 47.4
Tukang Masak 113 52.6

Gejala 71 33.0
Ya 144 67.0
Tidak

Keputusan Saringan (kadar serangan)
Positif
Negatif

Jadual 2: Penghuni maahad yang terdedah berdasarkan jantina dan pekerjaan

Pekerjaan Lelaki, Perempuan, Jumlah,
n (%) n (%) n

Pelajar 193 (95.5) 9 (4.5) 202
Guru 10 (90.9) 1 (9.1) 11
Tukang Masak 2 (100) 2
Jumlah 0 12 (5.6) 215
203 (94.4)

135

Jadual 3 pula menunjukkan bahawa semua 71 kes adalah dikalangan lelaki, tiada
kes dikalangan penghuni perempuan. Didapati juga penghuni yang positif hanya
dikalangan yang berumur antara 13 sehingga 23 tahun sahaja. Julat umur 13-18
adalah yang paling ramai dijangkiti iaitu seramai 51 (71.8%) orang berbanding 20
(28.2%) orang sahaja dikalangan julat umur 19-23 tahun. Semua kes-kes positif
adalah dikalangan pelajar sahaja.

Jadual 3 : Taburan sosiodemografik kes positif (n=71)

Faktor Sosiodemografik Lelaki Bilangan, n (%)
Jantina Perempuan 71 (100%)
13-18 tahun 0 (0%)
Julat umur 51 (71.8%)
19-23 tahun
20 (28.2%)

Jadual 4 menunjukkan bilik kediaman kes-kes yang positif. Didapati bilik cilik
mempunyai bilangan kes positif yang paling ramai, diikuti dengan bilik 1 dan bilik 11.
Pelajar yang mengalami onset terawal adalah dari bilik 11. Berdasarkan
pemerhatian lokasi dan infrastruktur asrama yang mempunyai kepadatan pelajar
yang agak tinggi dan pelajar-pelajar berkongsi bilik air dan tandas, agak sukar untuk
mengenalpasti punca jangkitan dikalangan pelajar. Ditambah pula dengan
pengamatan budaya pematuhan SOP dikalangan pelajar yang tidak begitu ketat dan
teratur, sukar untuk mengenalpasti punca jangkitan terawal. Didiapati juga 47.4%
pelajar adalah tiada gejala yang juga berkemungkinan menjadi punca tetapi tidak
dapat dikenalpasti tarikh mula jangkitan

Jadual 4 : Taburan sosiodemografik kes positif berdasarkan bilik pelajar (n=71)

Faktor Sosiodemografik (nama bilik) Bilangan
n (%)
Bilik Cilik
Bilik 1 15 (21.1%)
Bilik 11 9 (12.6%)
Bilik 2 9 (12.6%)
Bilik 5 7 (9.8%)
Anjung Mas 7 (9.8%)
Bilik 3 6 (8.4%)
Bilik 7 6 (8.4%)
Bilik 6 6 (8.4%)
Bilik Single 4 (5.6%)
2 (2.8%)

136

Berdasarkan rajah 1, seramai 102 orang yang terdedah adalah bergejala. Dari
jumlah ini, 53 orang adalah positif dan 49 orang lagi negatif. Analisa mendapati,
seramai 113 orang tidak bergejala. Walaupun tidak bergejala, didapati 18 orang
disahkan positif dan 95 yang lain adalah negatif.

B I L A N G A N K E S P O S I T I F D A N N E G A T I F B E R D A S A R K A N B E R G E J A L A A T A U T I D AK
(N=215)

POSITIF NEGATIF

BILANGAN
53

49
18

95

POSITIF GEJALA (102) TIADA GEJALA (113)
NEGATIF 53 18
49 95

Rajah 1 : Kes positif dan negatif berdasarkan gejala atau tidak bergejala

Rajah 2 menunjukkan gejala demam adalah gejala yang paling kerap dialami
dikalangan kes-kes positif, diikuti dengan gejala anosmia, batuk dan selsema.
Semua pelajar yang disahkan positif telah dihantar ke pusat kuarantin dan hospital
untuk tujuan isolasi dan rawatan lanjut.

KADAR SERANGAN MENGIKUT GEJALA

YA TIDAK

100% 35 45 46 49 53
90% 60 66 66
80% 36 26 25
70% 22 18 11 5 5
60% DEMAM ANOSMIA BATUK
50% SELSEMA TIADA GEJALA SAKIT KEPALA SAKIT TEKAK SAKIT BADAN
40%
30%
20%
10%
0%

Rajah 2 : Kadar Serangan Berdasarkan Jenis Gejala yang Dialami oleh Kes Positif

137

Rajah 3 menunjukkan keluk epid berdasarkan onset gejala dikalangan 53 kes
positif yang bergejala sahaja. Rajah 4 pula menunjukkan keluk epid berdasarkan
tarikh daftar kes untuk kesemua kes positif iaitu 71 kes. Tarikh daftar kes adalah

berdasarkan tarikh keputusan PCR.
Rajah 3: Keluk epid Kluster Dedap – berdasarkan onset gejala

Rajah 4: Keluk Epid Kluster Dedap-berdasarkan tarikh kes positif

138

Daripada hasil temuramah dan pemerhatian terhadap kepatuhan SOP, terdapat
beberapa faktor risiko telah dikenal pasti. Pertama, pembelajaran adalah tanpa
penjarakkan fizikal yang ditetapkan antara pelajar-pelajar dimana sesi pengajian
adalah dari pagi hingga ke petang. Kedua, di sebelah petang selepas waktu asar,
aktiviti riadah atau sukan telah diadakan di dalam kawasan sekolah walaupun SOP
pada masa tersebut tidak membenarkan. Ketiga, solat berjemaah diamalkan
sentiasa tetapi tiada penjarakkan fizikal seperti yang ditetapkan SOP. Keempat,
makanan telah disajikan didalam talam dan pelajar-pelajar berkongsi makan antara
satu sama lain dari talam dan semestinya tiada penjarakkan fizikal dan menyalahi
SOP yang sepatutnya. Kelima, didapati bilik penginapan murid-murid adalah sangat
padat dan rapat kedudukan antara katil-katil. Keenam, perkongsian bilik air dan
tandas antara pelajar-pelajar juga adalah faktor risiko yang jelas. Ketujuh, amalan
norma baharu seperti pemakaian pelitup muka dan pencucian tangan tidak diamati
dengan betul di dalam aktiviti seharian mereka.

PERBINCANGAN

Jangkitan COVID-19 yang berlaku di institusi pengajian adalah tidak asing lagi
bermula dari awal fasa pandemik sehingga kini. Antara faktor-faktor yang penting
dalam penularan COVID-19 dikalangan pelajar yang tinggal di asrama adalah
pengamatan budaya norma baharu seperti pemakaian pelitup muka yang betul,
penjarakkan fizikal dan amalan cuci tangan. Terdapat faktor seperti kesesuaian
fasiliti di sekolah dan asrama seperti penempatan pelajar-pelajar dalam bilik tidur
atau bilik darjah dan juga semasa aktiviti pembelajaran dijalankan. Menerusi hasil
kajian, didapati kes-kes positif hanyalah dikalangan pelajar lelaki. Pelajar
perempuan dan guru-guru adalah negatif. Kadar serangan adalah 33 % iaitu 71
orang daripada 215 jumlah penghuni.

Kluster Dedap ini terjadi semasa dalam fasa PKPB (Perintah Kawalan Pergerakan
Bersyarat) yang berkuatkuasa dari 19.2.2021 sehingga 4.3.202. Berdasarkan
penyiasatan dan pemerhatian yang dibuat, terdapat beberapa perkara yang tidak
dipatuhi oleh pihak sekolah seperti yang diarahkan oleh pihak MKN (Majlis
Keselamatan Negara) melalui sumber rujukan iaitu SOP PERINTAH KAWALAN
PERGERAKAN BERSYARAT (PKPB) DIKEMASKINI: 18 FEBRUARI 2021 (Majlis
Keselamatan Negara, 2021). Kementerian Pendidikan Malaysia juga pada waktu itu
telah menerbitkan GARIS PANDUAN PENGURUSAN DAN PENGOPERASIAN
SEKOLAH DALAM NORMA BAHARU 2.0, sebagai garis panduan (Kementerian
Pendidikan Malaysi, 2021).

139

Pertama sekali, berdasarkan keluk epid dan kronologi Kluster Dedap didapati
terdapat kelewatan dalam pengesanan dan rawatan. Hal ini boleh dilihat pada tarikh
terima notifikasi bagi kes indeks atau kes pertama dikesan adalah pada 8.2.2021
tetapi kes tersebut telah mempunyai onset gejala pada 3.2.2021. Perbezaan masa
yang agak lama ini menunjukkan kelewatan dalam mengenalpasti potensi wujudnya
jangkitan di kalangan pelajar-pelajar lain. Pada keluk epid tersebut juga, onset
terawal adalah pada 28.1.2021 yang berkemungkinan menjadi punca kepada
penularan kluster, tetapi kelewatan dalam pengesanan berpotensi menyebabkan
penularan di kalangan pelajar lain. Pengesanan gejala pada peringkat awal sudah
pasti dapat mengekang penyebaran jangkitan.

Seterusnya, melalui penyiasatan yang telah dibuat berdasarkan temuramah dengan
pihak maahad, terdapat beberapa faktor yang menjadi potensi mudahnya
penyebaran jangkitan. Cara pembelajaran adalah secara bersemuka di dalam
kawasan sekolah termasuk surau. Didapati tiada penjarakkan semasa sesi
pembelajaran dan juga semasa solat berjemaah. Selain itu, disiplin dalam
pematuhan pemakaian topeng muka juga adalah kurang memuaskan. Semasa
makan, pelajar-pelajar mengamalkan makan kongsi bersama menggunakan talam
yang sudah pasti tiada panjarakkan dan meningkatkan jangkitan menerusi sentuhan
objek yang tercemar dengan virus.

COVID-19 adalah satu virus yang berjangkit melalui titisan saluran pernafasan dan
juga permukaan yang tercemar. Selain isu pematuhan amalan norma baharu, faktor
persekitaran seperti bilik tidur dan bilik darjah yang mempunyai keluasan yang
bersesuaian, pengudaraan dan pencahayaan yang baik dapat mengurangkan risiko
penyebaran virus. Bilik asrama pelajar menempatkan ramai pelajar yang
menyebabkan sesuatu bilik itu sempit atau ‘crowded’. Pelajar-pelajar juga harus
berkongsi bilik air dan tiada aktitviti sanitasi permukaan dijalankan secara berkala.
Hal-hal ini haruslah sejajar dengan pengamatan dan pembudayaan norma baharu
supaya penyebaran virus COVID-19 dapat dibendung.

Berdasarkan temuramah yang telah dibuat, didapati 6 bulan sebelum terjadinya
Kluster Dedap ini, semua pelajar hanya berada di sekolah dan tidak pulang atau
datang dari kawasan luar selain kawasan sekolah. Punca jangkitan tidak dapat
dikenalpasti secara tepat, tetapi terdapat pelajar – pelajar menyelinap keluar dari
maahad tahfiz ke kedai-kedai sekitar maahad melalui ladang kambing dan lembu di
belakang maahad. Selain itu, terdapat juga pelajar yang mendapat keizinan untuk
keluar masuk dan mendapat ‘pass’ untuk tujuan membeli barang-barang yang

140

kebanyakkan dari Alor Setar dan Kuala Muda. Walau punca jangkitan tidak dapat
dipastikan dengan tepat, pemantauan oleh pihak institusi harus lebih ketat dan teliti
seperti aktiviti penyeliaan pergerakan pelajar-pelajar oleh pihak sekolah dan
pemantauan suhu dan gejala semasa ‘gatekeeping’. Pemantauan gejala dan suhu
juga seharusnya dijalankan sebagai jadual harian.

Menerusi temuramah dan pemerhatian di kawasan sekolah, tiada bahan Pendidikan
kesihatan mengenai COVID-19. Pendedahan kepada media juga adalah kurang dan
terbatas. Hal ini berkemungkinan menyebabkan pendedahan berterusan mengenai
COVID-19 tidak sampai kepada para pelajar. Penghayatan kepada aspek norma
baharu juga pada waktu itu, berkemungkinan, tidak dapat diterapkan dengan baik
atas sebab ketiadaan informasi-informasi dan juga bahan-bahan pendidikan yang
mencukupi.

AKTIVITI YANG DIJALANKAN DALAM USAHA MENGEKANG PENULARAN
KLUSTER DEDAP

I. Mesyuarat bencana PKOB diadakan bagi mendapat kerjasama dan
menyalurkan maklumat supaya aktiviti kawalan penyakit dapat dijalankan
dengan sistematik dan teratur. Mesyuarat ini dipengerusikan oleh Pegawai
Daerah dan melibatkan agensi-agensi yang berkepentingan seperti Pejabat
Kesihatan Daerah, Polis Diraja Malaysia, Pejabat Pendidikan Daerah dan
Jabatan Pertahanan Awam.

II. Arahan kuarantin (HSO) dan gelang kepada semua ‘close contact’ dan
‘potential contact’ – tindakan ini bagi mengawal penularan jangkitan dengan
lebih cepat. Pengawasan keluar masuk berterusan oleh polis dan rela –
kerjasama antara agensi lain seperti polis dan rela amatlah diperlukan.
Persefahaman dari pihak polis dan rela membolehkan aktiviti pengawasan ini
dijalankan dengan sangat rapi. Semua yang digelangkan akan ditempatkan
di kawasan sekolah dan keluar masuk tidak dibenarkan.

III. Banner ‘zon merah’ dipamerkan sekitar Kawasan Dedap – ini adalah untuk
memberi peringatan kepada komuniti setempat untuk lebih berjaga-berjaga
dan mengikut SOP dan arahan pihak berkuasa pada setiap masa. Aktiviti
hebahan awam dan promosi – aktiviti-aktiviti seperti hebahan mengenai
penyebaran dan bahaya COVID-19 dijalankan secara harian dengan bantuan
pihak jabatan penerangan.

IV. Taklimat Pendidikan kesihatan – taklimat Pendidikan kesihatan diberikan
oleh Pegawai Kesihatan Daerah kepada pelajar-pelajar dan guru-guru di
institusi tersebut. Pemantauan SOP di sekolah Maahad lain di daerah Yan –
berikutan Kluster Dedap ini, maahad-maahad lain juga diberi perhatian lebih
untuk mengelakkan kejadian sama berlaku.
141

KESIMPULAN

Penularan COVID-19 di institusi pengajian adalah kejadian yang sering berlaku
semasa fasa pandemik. Aspek pematuhan SOP oleh pelajar-pelajar, guru-guru dan
pengurusan sekolah memainkan peranan yang paling utama dalam mengelakkan
dan membendung penularan wabak COVID-19 di premis pembelajaran. Terdapat
beberapa perkara yang perlu diperbaiki dan diambil iktibar seperti saringan suhu
dan gejala di kalangan pelajar-pelajar, kepentingan mengambil rawatan awal dan
melakukan ujian COVID-19, pematuhan SOP seperti pemakaian topeng muka
dengan betul, penjarakkan fizikal semasa dalam sesi pembelajaran dan di asrama,
pendedahan berterusan dan penekanan kepada bahanya COVID-19. Semua SOP
ini telah termaktub di dalam arahan MKN dan juga KPM, pengurusan sekolah harus
sentiasa lebih peka dan melakukan penyeliaan secara berkala.

PENGHARGAAN

Penulis ingin mengucapkan setinggi-tinggi penghargaan kepada Ketua Pengarah
Kesihatan kerana kebenaran untuk menerbitkan artikel ini

RUJUKAN

van, M. A., (2020). Memahami Pandemik Covid-19 Dalam Perspektif Psikologi

Sosial. Dipetik daripada http://ejournal.uin-

suska.ac.id/index.php/Psikobuletin/article/view/9616

Kementerian Kesihatan Malaysia, (n. d.). Soalan Lazim Penyakit Coronavirus

(Covid-19). Dipetik daripada http://www.myhealth.gov.my/wp

Majlis Keselamatan Negara. SOP Perintah Kawalan Pergerakan Bersyarat (PKPB)

Dikemaskini : 18 Februari 2021

Kementerian Pendidikan Malaysia (2021). Garis Panduan Pengurusan dan

Pengoperasian Sekolah dalam Norma Baharu 2.0

https://www.who.int/emergencies/diseases/novel-coronavirus-2019

COVID-19 in schools: Mitigating classroom clusters in the context of variable

transmission

https://journals.plos.org/ploscompbiol/article?id=10.1371/journal.pcbi.10091

20

Sri Petaling COVID-19 cluster in Malaysia: challenges and the mitigation strategies

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7927555/

142

IMPAK PANDEMIK COVID-19 TERHADAP PENGGUNAAN
PERKHIDMATAN PERGIGIAN PRIMER DI NEGERI KEDAH

Dr. Nurul Fahizha1, Dr. Nama Bibi Saerah1, Dr. Ruhaini1, Dr. Hilmun Hanim1

Dr Rosidah binti Omar2

1 Bahagian Kesihatan Pergigian Jabatan Kesihatan Negeri Kedah
2 Unit Kesihatan Pekerjaan dan Alam Sekitar, JKN Kedah
*Corresponding author: Ruhaini Sabron, [email protected]
__________________________________________________________________

ABSTRAK

Latar Belakang: Tujuan kajian ini dijalankan adalah untuk menerangkan penggunaan
perkhidmatan kesihatan pergigian semasa pandemik COVID-19 dari segi tren kehadiran
pesakit luar ke Klinik Pergigian Primer dan rawatan pergigian yang diberikan dari tahun 2019
hingga 2021.

Methodologi: Ini adalah kajian rentas melibatkan analisa data sekunder penggunaan
perkhidmatan kesihatan pergigian di Negeri Kedah dari tahun 2019 hingga 2021 yang
diperoleh dari reten bulanan dari klinik atau daerah. Data yang dikaji ialah kedatangan
pesakit ke Klinik Pergigian Primer dan jenis rawatan pergigian yang diberikan.

Keputusan: Jumlah kedatangan pesakit di Klinik Pergigian Primer bagi tahun 2019 ialah
seramai 824,934 orang, tahun 2020 seramai 392,821 (penurunan 52.4% berbanding 2019)
dan tahun 2021 seramai 284,248 (penurunan 27.6% berbanding 2020). Jumlah kes
kecemasan di Klinik Pergigian Primer bagi tahun 2019 ialah seramai 315,582, tahun 2020
seramai 151,731 (penurunan 51.9% berbanding 2019), tahun 2021 seramai 148,237
(penurunan 2.3% berbanding 2020). Rawatan cabutan dan tampalan menunjukkan
penurunan paling ketara bagi kes kecemasan dan elektif pada tahun 2020 berbanding 2019.

Kesimpulan: Terdapat penurunan penggunaan perkhidmatan Klinik Pergigian Primer di
JKN Kedah dari segi kehadiran pesakit ke klinik dan rawatan kecemasan dan elektif yang
diberikan semasa pandemik COVID-19. Hal ini mungkin disebabkan risiko penularan yang
tinggi dan SOP yang ketat menyebabkan hanya kes-kes kecemasan yang diterima. Selain
itu, ini disebabkan oleh penutupan premis gunasama UTC sepanjang tempoh PKP yang
menempatkan 2 klinik pergigian, menyebabkan operasi klinik terpaksa ditangguhkan. Oleh
itu, bagi menjamin pemberian perkhidmatan pergigian yang berterusan dan mengurangkan
risiko jangkitan, dicadangkan pihak klinik membuat perancangan awal mengenai rawatan
kes, mempertingkatkan amalan norma baharu semasa di tempat kerja, penggunaan tele-
health (temujanji atas talian) dan kawalan kejuruteraan seperti bilik khas untuk prosedur
AGP.

143

PENGENALAN

Pandemik COVID-19 telah memberikan impak kepada kesihatan, ekonomi dan
sosial di seluruh dunia. Pelbagai strategi dan langkah pencegahan dilaksanakan
bagi mengekang penularan virus ini.

Penggunaan perkhidmatan kesihatan (healthcare utilization) adalah rendah semasa
pandemik COVID-19 disebabkan oleh sekatan pergerakan, keperluan penjarakan
sosial, risiko mendapat jangkitan nosokomial atau penangguhan rawatan selain
COVID. Magnitud kesan pandemik ini berbeza mengikut jenis perkhidmatan
kesihatan. Kajian skop oleh Izani, Jaafar, & Mohd Nor M.(2022) tentang kesan
COVID-19 kepada penggunaan perkhidmatan kesihatan di Malaysia menunjukkan
pengurangan prosedur pembedahan 23% hingga 83%, pengurangan 57.8%
kehadiran pesakit luar di klinik dan pengurangan kemasukan ke wad untuk kes
denggi sebanyak 35.8% hingga 57.6% (Izani, Jaafar, & Mohd Nor M, 2022). Faktor
utama tren pengunaan yang rendah ini adalah disebabkan arahan pentadbiran yang
dikeluarkan dalam usaha untuk mengurangkan risiko jangkitan COVID-19.
Diperingkat kebangsaan, antara langkah kerajaan untuk mengekang penularan
COVID-19 di Malaysia ialah dengan melaksanakan perintah Kawalan Pergerakan
mengikut fasa berikut:

 Perintah Kawalan Pergerakan (PKP)
o Fasa 1: 18 - 31 Mac 2020
o Fasa 2: 1 - 14 April 2020
o Fasa 3: 15 – 28 April 2020
o Fasa 4: 29 April – 3 Mei 2020
 Perintah Kawalan Pergerakan Bersyarat: 4 Mei – 20 Jun 2020
 Perintah Kawalan Pergerakan Pemulihan: 21 Jun – 31 Disember 2020

Dalam sektor kesihatan pergigian, pandemik COVID-19 juga telah menghadkan
akses kepada sistem penjagaan kesihatan pergigian disebabkan perkhidmatan ini
melibatkan aerosol generating prosedur (AGP) yang boleh meningkatkan risiko
jangkitan dan penyebaran COVID-19. Bahagian kesihatan pergigian telah
melaporkan pengurangan kapasiti disebabkan oleh penutupan dan keperluan untuk
langkah kawalan jangkitan tambahan seperti disinfeksi dan “fallow time” (General
Dental Council, 2020).

Mengambil langkah proaktif, Kementerian Kesihatan Malaysia telah merangka garis
panduan dan polisi untuk meminumkan penyebaran jangkitan bagi memastikan
keselamatan petugas kesihatan semasa pemberian perkhidmatan pergigian. Ketika
pelaksanaan PKP Fasa 1, Program Kesihatan Pergigian Kementerian Kesihatan
Malaysia telah mengeluarkan Garis Panduan Perkhidmatan Kesihatan Pergigian

144

Pasca Perintah Kawalan Pergerakan Pandemik COVID-19 No 1/2020 sebagai
panduan dalam pemberian perkhidmatan kesihatan pergigian (MOH, 2020).
Berpandukan garis panduan tersebut, hanya rawatan kecemasan yang dibenarkan
untuk dijalankan kepada pesakit. Jenis rawatan kecemasan adalah seperti sakit gigi
(skor kesakitan > 4), cabutan gigi disebabkan oleh pulpitis tidak berbalik dan
periodontitis periapikal akut, tampalan pecah/ aplian/ prostesis patah yang boleh
menyebabkan kecederaan pada tisu mulut dan kesakitan, kecederaan mulut / gigi
akibat terjatuh atau sebarang trauma, Trigeminal neuralgia, abses, Lesi mulut dan
ketumbuhan yang disyaki malignan dan komplikasi selepas cabutan seperti
pendarahan, dry socket dan jangkitan kuman.

Kajian mengenai penggunaan perkhidmatan pergigian semasa pandemik di negeri
Kedah adalah kurang jelas. Oleh itu, tujuan kajian ini dijalankan adalah untuk
menerangkan penggunaan perkhidmatan kesihatan pergigian semasa pandemic
COVID-19 dari segi tren kehadiran pesakit luar ke Klinik Pergigian Primer dan
rawatan pergigian yang diberikan dari tahun 2019 hingga 2021. Kajian ini adalah
penting kepada pembuat polisi untuk merancang strategi dan kaedah pelaksanaan
terbaik bagi memastikan pemberian perkhidmatan pergigian dapat diteruskan dalam
era pandemik ini.

METODOLOGI

Rekabentuk kajian ini menggunakan kaedah keratan rentas melibatkan
pengumpulan data sekunder penggunaan perkhidmatan kesihatan pergigian di
Negeri Kedah dari tahun 2019 hingga 2021. Pengumpulan data adalah pada Januari
2022. Data diperoleh dari reten bulanan dari klinik pergigian primer dari setiap
daerah. Data yang dikaji ialah kedatangan pesakit ke Klinik Pergigian Primer dan
jenis rawatan pergigian yang diberikan. Data dianalisa secara deskriptif
menggunakan Microsoft Excel.

KEPUTUSAN

Tren kedatangan pesakit ke Klinik Pergigian Primer

Rajah 1 menunjukkan tren kedatangan pesakit ke Klinik Pergigian Primer di negeri
Kedah bagi tahun 2019-2021. Sebelum pandemik bermula iaitu pada tahun 2019,
jumlah kedatangan pesakit di Klinik Pergigian Primer adalah tinggi seramai 824,934.
Kedatangan paling tinggi adalah di daerah Kota Setar 170,428 (20.7%), diikuti Kuala
Muda 170159 (20.6%) dan Kubang Pasu 105350 (12.8%). Walaubagaimanapun,
ketika pandemik tahun 2020, kedatangan ke klinik menurun kepada 392,821 pesakit
iaitu penurunan sebanyak 52.4% berbanding tahun pre-pandemik 2019.

145

Tren penurunan adalah berterusan pada 2021 iaitu kedatangan ke klinik hanya
284,248 pesakit iaitu penurunan sebanyak 65.5% berbanding tahun pre-pandemik
2019 dan 27.6% berbanding tahun 2020.

Untuk mengekang penularan COVID-19, kerajaan telah melaksanakan perintah
kawalan pergerakan pada Mac 2020. Rajah 2 menunjukkan tren kedatangan pesakit
di Klinik Pergigian Primer selepas pelaksanaan PKP iaitu dari bulan April sehingga
Disember 2020. Analisa menunjukkan kedatangan pesakit bagi tempoh 9 bulan ini
hanyalah 163,730 (41.6%). Dari jumlah ini, seramai 111,036 (67.8%) kes adalah
kedatangan baru dan 52,694 (32.2%) adalah pesakit ulangan. Analisa mengikut
bulan menunjukkan pada bulan Mei 2020 iaitu ketika PKPB (Bersyarat) mencatatkan
kedatangan paling rendah iaitu seramai 6415 pesakit. Manakala, kedatangan paling
tinggi ialah pada bulan Disember 2020 (PKP Pemulihan) iaitu seramai 27,765 orang
pesakit. Daerah Kuala Muda mencatatkan kedatangan pesakit paling tinggi iaitu
seramai 32,815 (20.0%) pesakit, diikuti daerah Kota Setar seramai 28,244 (17.3%)
dan Kubang Pasu seramai 17,193 (10.5%) pesakit. Daerah yang paling kurang
kedatangan pesakit ke Klinik Pergigian ialah daerah Bandar Baharu dengan 3765
(2.4%) pesakit.

900000

800000

700000

600000

500000

400000

300000

200000

100000

0 Yan Padang Langka Baling Kubang Kulim Bandar Kuala Sik Kota Pendan Kedah
Terap wi Pasu Baharu Muda Setar g
2019 38791 36187 42973 71343 31753
2020 20386 37113 105350 104488 18010 170159 18505 170428 35452 824934
2021 14147 22410 30490 26914 10855
45733 38720 8587 76616 77861 16400 392821
17267 24243
35577 25495 6721 52451 60750 9828 284248

Rajah 1: Tren Kedatangan Pesakit ke Klinik Pergigian Primer bagi tahun 2019 -
2021.

146

30000

25000

Bilangan pesakit 20000

15000

10000

5000

0 Yan Padang Langka Kubang Kulim Bandar Baling Kuala Sik Kota Pendan Kedah
Terap wi Pasu Baharu Muda Setar g
April 220 629 471 1829 771 3410 322 2851
Mei 236 377 406 976 580 145 596 1139 169 1553 385 11629
Jun 638 891 1127 1440 842 2015 463 2557
Julai 1107 1288 1607 2353 1658 117 683 4456 659 4827 179 6415
Ogos 1070 777 1963 2220 1997 4595 777 4867
September 1007 1345 2477 2999 1933 232 2365 3388 1263 3218 468 13038
Oktober 1616 3168 2397 1494 2080 4000 2276 1099
November 1729 1712 3116 1458 1564 357 2652 3413 1682 1402 797 21761
Disember 1589 1502 2398 2424 2408 6399 1039 5870
469 2128 762 21625

707 1830 796 20963

655 1583 941 21309

343 1420 1386 19225

740 2588 808 27765

Rajah 2: Tren Kedatangan Pesakit ke Klinik Pergigian Primer semasa fasa PKP
(April –Disember 2020)

Tren pemberian rawatan pergigian

Jadual 1 menunjukkan bilangan pesakit mendapatkan rawatan kecemasan di Klinik
Pergigian Primer bagi tahun 2019 hingga 2021. Pada tahun pre-pandemik 2019,
kedatangan pesakit yang mendapatkan rawatan kecemasan di Klinik Pergigian
primer adalah seramai 315,582 pesakit. Jumlah ini berkurangan kepada 151, 731
pesakit pada tahun 2020 iaitu pengurangan sebanyak 51.9% berbanding tahun pre-
pandemik 2019. Pengurangan kehadiran pesakit berterusan pada 2021 dengan
hanya 148,237 pesakit mendapatkan rawatan kecemasan di klinik iaitu
pengurangan sebanyak 2.3% berbanding 2020 dan 53.0% berbanding 2019. Tren
penurunan ini adalah disumbangkan oleh penurunan kes bagi dua prosedur utama
iaitu tampalan dan cabutan gigi. Pengurangan paling ketara adalah melibatkan kes
untuk tampalan iaitu 163,171 pada 2019 menurun kepada 52,863 pada 2020
(penurunan 67.6%). Tren penurunan juga dilihat untuk kes cabutan gigi iaitu 137,
665 pada 2019 berbanding hanya 85,667 kes pada 2020 (penurunan 37.8%).

147

Jadual 1: Bilangan kes kecemasan di Klinik Pergigian Primer 2019-2021

Bil. Kes Kecemasan 2019 2020 2021

N%N%N %

Kecederaan tisu mulut 749 0.2 682 0.4 622 0.4
Lesi mulut dan 406 0.1 356 0.2 355 0.2
ketumbuhan
Facial Cellulitis/abses 12700 4.0 11389 7.5 7252 4.9
Cabutan gigi 137665 43.6 85667 56.5 84835 57.2
Komplikasi selepas 0.5 0.6
cabutan 891 0.3 774 908
Tampalan
Jumlah 163171 51.7 52863 34.8 54265 36.6
315582 100.0 151731 100.0 148237 100.0

Selain kes kecemasan, rawatan elektif seperti cabutan gigi, tampalan, pemberian
ubat, penskaleran, dentur dan lain-lain masih diteruskan di Klinik Pergigian Primer.
Rajah 3 menunjukkan jumlah rawatan elektif di Klinik Pergigian Primer bagi tempoh
2019-2021. Analisa data menunjukkan, pada 2019 kes rawatan elektif adalah tinggi
iaitu 439, 441. Jumlah ini berkurangan kepada 214,330 pada 2020 (penurunan
51.2% berbanding 2019) dan 167,710 pada 2021 (penurunan 21.8% berbanding
2020).

Tren penurunan ini disumbangkan oleh penurunan tiga prosedur elektif utama iaitu
cabutan gigi, tampalan dan penskaleran. Prosedur elektif pada 2019 sebanyak
137,665 (Cabutan gigi), 163,171 (tampalan) dan 62,913 (penskaleran). Prosedur
elektif pada 2020 adalah cabutan gigi sebanyak 85667 (penurunan 37.8%
berbanding 2019), tampalan gigi sebanyak 52863 (penurunan 67.6% berbanding
2019) dan penskaleran sebanyak 18843 (penurunan 70% berbanding 2019).

Bil Rawatan 450000
400000
350000 Pemberian
300000 Ubat
250000
200000 61549
150000
100000 48309

50000
0

Cabutan gigi Tampalan Penskaleran Dentur Lain-lain Jumlah

2019 137665 163171 62913 8297 5846 439441
2020 85667 52863 18843 5577 3071 214330
2021 84835 54391 18587 6505 3392 167710

Rajah 3: Jumlah Rawatan Elektif di Klinik Pergigian Primer bagi tahun 2019 -2021.

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PERBINCANGAN

Tujuan kajian ini dijalankan adalah untuk menerangkan penggunaan perkhidmatan
kesihatan pergigian semasa pandemik COVID-19 dari segi tren kehadiran pesakit
luar ke Klinik Pergigian Primer dan rawatan pergigian yang diberikan dari tahun 2019
hingga 2021. Hasil kajian mendapati, tren penurunan yang ketara bagi kedatangan
pesakit bagi tahun pandemik 2020 dan 2021 berbanding tahun pre-pandemik 2019.
Hal ini berlaku kerana beberapa arahan pentadbiran untuk mengekang penularan
COVID-19 dimana perkhidmatan elektif terpaksa ditangguhkan semasa perintah
kawalan pergerakan dan hanya kes-kes kecemasan di rawat di Klinik Pergigian
Primer (MOH, 2020). Tambahan pula susulan PKP ini, banyak premis-premis yang
ditutup oleh pihak berkuasa tempatan dimana premis ini adalah bangunan
gunasama yang menempatkan klinik pergigian seperti di Klinik Pergigian UTC
Sungai Petani dan Klinik Pergigian UTC Alor Setar. Selain itu, Klinik Pergigian
Kepala Batas yang sedang di dalam pembinaan di bawah projek RMK-11 juga tidak
dapat beroperasi.

Walaupun rawatan kes-kes kecemasan diteruskan semasa PKP, secara
keseluruhannya kajian ini menunjukkan jumlah kes-kes kecemasan berkurangan
pada tahun 2020 dan 2021 berbanding tahun pre-pandemik 2019. Penurunan ketara
yang dapat dilihat untuk kes kecemasan melibatkan cabutan gigi dan tampalan. Hal
ini mungkin disebabkan pesakit tidak mengetahui bahawa perkhidmatan kecemasan
masih disediakan walaupun semasa PKP. Melalui tinjauan yang dijalankan di United
Kingdom, 43% responden tidak mengetahui perkhidmatan kecemasan masih
disediakan semasa tempoh berkurung apabila temujanji awal telah dibatalkan
(General Dental Council, 2020)

Tren yang sama ditunjukkan untuk rawatan elektif dimana tren penurunan untuk
prosedur penskaleran, tampalan dan cabutan gigi semasa pandemik. Pesakit
mungkin mendapatkan rawatan di swasta yang kurang sesak bagi rawatan
penskaleran, cabutan gigi dan tampalan bagi mengurangkan risiko pendedahan
disamping kos yang mampu milik untuk prosedur ini. Kajian di UK menunjukkan
dikalangan responden yang mempunyai masalah gigi semasa tempoh berkurung,
51% tidak berbuat apa-apa dan sanggup menunggu sehingga tempoh berkurung
selesai, 14% membuat rawatan sendiri dan hanya 35% menggunakan khidmat
profesional (General Dental Council, 2020). Pandemik COVID-19 masih belum
menunjukkan tanda reda. Berdasarkan hasil kajian ini, beberapa cadangan
penambahbaikan boleh dijalankan untuk memastikan pemberian kesihatan
pergigian yang berterusan kepada pesakit sepanjang pandemik ini. Pertamanya,
perkhidmatan kesihatan pergigian perlulah merancang rawatan pesakit dengan
lebih teliti untuk mengelakkan pendedahan yang tidak perlu kepada pesakit yang

149