Laporan Teknikal Jabatan Kesihatan Negeri Kedah 2022

In the present study, the overall mean score was slightly higher than that of a study
conducted among pharmacists in Melaka (67.82 versus 65.6). Five out of six
dimensions had higher mean scores compared to those recorded by Samsuri et al.
(2015); in increasing score order, they were working condition (62.27 versus 54.8),
perception of management (64.87 versus 62.20), teamwork climate (69.18 versus
67.6), safety climate (69.36 versus 66.8), and job satisfaction (76.54 versus 67.3).
Compared with international benchmarking data, safety climate, job satisfaction,
perception of management, and working condition dimensions had higher mean
scores, while the teamwork climate mean score was comparable to the
benchmarking data (John B Sexton et al., 2006).

In the study, the stress recognition dimension had a lower mean score compared to
international benchmarking data by Sexton et al. (2006) (62.80 versus 65.90), and
other international studies,(Cheng et al., 2019; Elsous et al., 2016; John B Sexton et
al., 2006) and the local research by Samsuri et al. (2015). The stress recognition
dimension is defined as an acknowledgement of how stressors influence
performance; a lower score means that the surveyed staff members have relatively
low recognition of the performance consequences of stress and fatigue. This sense
of invulnerability can also be observed in several other professions such as in the
aviation industry and appears to be more prevalent in healthcare settings.(Poley,
van der Starre, van den Bos, van Dijk, & Tibboel, 2011; J Bryan Sexton, Thomas, &
Helmreich, 2000) Our results showing that medical workers do not fully understand
the impact of stress and exhaustion mirror the findings of others,(Cui et al., 2017;
Zulkipli, Taib, Samsuddin, & Isa, 2018) as they are too accustomed to busy work
schedules and heavy workloads. Therefore, staff members should admit that stress,
high workload, and sleep deprivation are among the causes of reduced job
performance and increased risk of medical errors.

Although higher than the international benchmarking scores, the mean score of the
working condition dimension reported in our study was the lowest among the six
dimensions examined. This finding is similar to that of some studies.(Cheng et al.,
2019; Poley et al., 2011; Samsuri et al., 2015; Sarifulnizam et al., 2019) The mean
score and positive response rate were lowest in the NLH, compared to the LH. This
finding reflects employees’ frustration with work environment quality and logistic
support such as staffing and equipment. Further analysis of the items under this
dimension revealed that most respondents from both the LH and NLH disagreed with
the statement “the level of staffing in this clinical area is sufficient to handle the
number of patients.” This finding is expected from respondents in the LH, which is a
state tertiary hospital with a high workload. However, the NLH respondents also
indicated insufficient levels of staffing at their hospitals. This observation may be
because although the NLH is a non-specialist district hospital, the workload has risen

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following the extension of specialist services to the NLH after the cluster hospital
model was introduced; however, the number of staff remained the same. Lack of
staff, increased patient volume, expansion of clinical services, and higher
expectations from other healthcare professionals may have contributed to the
increased workload, which could jeopardize patient safety.

The job satisfaction dimension had the highest positive response rate among all
dimensions in the SAQ, despite most staff being dissatisfied with their working
conditions. Our finding is congruent with that of local studies conducted at teaching
hospitals and public hospitals (A. Ismail et al., 2020; Sarifulnizam et al., 2019). Here,
67.0% of the respondents had a positive response (score > 75%) for this dimension,
which is higher than that reported in local studies (A. Ismail et al., 2020; Samsuri et
al., 2015) as well as international benchmarking data,(John B Sexton et al., 2006)
wherein the positive response rate was 46.2–62.7%. Our finding is also consistent
with other previous studies (Cui et al., 2017; Elsous et al., 2016). Job satisfaction
positivity indicates that most of the cluster hospital staff, especially the NLH staff, are
relatively pleased with their jobs and that they have positive work experiences. This
finding is based on the high percentage of participants who answered positively for
the item “I like my job” (82.6%), the highest scored item in the SAQ. The value of job
satisfaction cannot be overlooked because it is imperative that it increases workers’
enthusiasm and enhances work efficiency and quality, indirectly improving patient
safety. Those with higher job satisfaction would more likely be actively involved in
accepting and implementing future quality-enhancement strategies.

Our study also reveals that the teamwork climate and safety climate had the second
highest mean scores after the job satisfaction dimension, with 37.1% and 36.2%
positive responses, respectively, which is similar to other studies.(Alqahtani & Evley,
2020; Samsuri et al., 2015; John B Sexton et al., 2006; Zulkipli et al., 2018) Two
items scored lowest under these dimensions: The respondents perceived difficulty
in reporting problems with patient care, and it was also difficult to discuss errors in
their clinical area, indicating that the existing culture in that area was unreliable and
discouraging toward a patient safety culture and incident reporting. Experts state
that the influence of teamwork should not be underestimated. (Nieva & Sorra, 2003).
Many studies have shown that teamwork can dramatically enhance patient
outcomes and reduce preventable errors (Lo, 2011; Walton et al., 2010). In the
current dynamic medical climate, healthcare professionals have recognized the
value of knowledge and complementary skills. However, mutual confidence and two-
way communication capabilities between team members should be strengthened. A
survey also concluded that the principal characteristics of a safety culture are
teamwork within the unit and honest and open communication among healthcare
professionals and with patients.(Abdou & Saber, 2011) Thus, improvements should

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be made to encourage staff to communicate, particularly when patient care and
safety are concerned.

The predictive factors identified as significantly associated with positive patient-
safety culture are similar to most studies. Those working in surgery- and medical-
based departments were more likely to have a positive patient-safety culture, relative
to other categories. The findings may be linked to their working environment, which
may cause them to perceive safety issues differently. Other departments may not
consider some of these issues as relevant (Brasaite et al., 2016). Those in surgery-
based departments deal with surgical procedures; thus, they are more susceptible
to patient safety concerns, as they could face medicolegal implications for an error
or incident such as incorrect surgery and retained foreign bodies such as gauze.

Patient safety-related training and education were identified as other important
factors in achieving improved patient safety (Nygren et al., 2013). This finding is
congruent with a study conducted in Kuwait, which found that the perception of
patient safety culture decreased among those who did not attend patient safety
courses or lectures (Alqattan, Cleland, & Morrison, 2018; Brasaite et al., 2016).
Further, healthcare professionals who did not receive any information about patient
safety, either during their initial professional education or throughout their
professions, had more negative attitudes to most of the dimensions of patient safety,
compared to those who had received the information. A study that examined the
effect of training on nurses’ attitudes towards patient safety found that training had
a significant positive impact on nurses’ safety attitudes, particularly on the perception
of management, job satisfaction, and safety climate dimensions (Azimi, Tabibi,
Maleki, Nasiripour, & Mahmoodi, 2012). Our finding is also in line with that of other
studies (Ridelberg, Roback, & Nilsen, 2014; Wami, Demssie, Wassie, & Ahmed,
2016).

Consequently, we may conclude that patient safety education is vital in healthcare
professionals’ patient safety attitudes. Organizational learning and continuous
development such as staff training are reported as strengths due to the capacity of
healthcare organizations to create a knowledge-enhancing environment for learning.
Realizing the importance of training, the MOH Patient Safety Unit has incorporated
a patient safety-training module for house officers during their orientation programs
before they begin their graduate training. The course, which is inspired by the WHO
Multi-professional Curriculum Guide, is intended to provide house officers with
relevant exposure and information to enhance patient safety. For the other
healthcare professional categories, our cluster hospital has developed an initiative
to conduct multiple courses regularly to ensure continuous awareness and updated
patient safety knowledge.

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Incident reporting, root causes, and risk analyses were also identified as the most
critical factors for achieving positive patient safety culture. Our study shows a
significant association between the incident reporting system and positive patient
safety culture. The association between a non-punitive reporting system and patient
safety culture is in line with most studies on patient safety factors.(Gaal, Verstappen,
& Wensing, 2011; Mahrous, 2018; Nygren et al., 2013; Ridelberg et al., 2014; Tear,
Reader, Shorrock, & Kirwan, 2020; Wami et al., 2016) Most studies also mention a
lower response toward non-punitive responses to error (Alqattan et al., 2018; Alswat
et al., 2017; Mahrous, 2018). Such findings indicate that a blame-and-shame culture
in the workplace hinders accountability and causes workers to feel insecure and
become prone to hiding their shortcomings, rather than sharing their concerns
related to patient safety. Working in such an atmosphere would hinder learning from
mistakes; individuals would only be criticized and punished, while system errors are
overlooked.

Another study conducted in Beijing found that effective safety culture had not been
achieved, as the incidents reported did not receive useful feedback, and openly
discussing errors and incidents in the department were not encouraged (Cui et al.,
2017). This situation is similar to that of our study, in which 36.0% of respondents
agreed that discussing errors in their clinical areas was challenging. However, most
of our respondents agreed that they learned from the incidents reported. This was
achieved by ensuring that staff members were informed about the incidents or errors
and advised on the changes implemented. The practices and guidelines for
preventing errors were also reviewed appropriately. Health care organizations
should use incident reporting to strengthen patient safety culture and improve
service quality. This can transform an organization’s existing blame culture, from one
where an error is viewed as a personal failure to one where errors are considered
potential areas for improvement.

It is noteworthy that the multivariate analysis model developed in the present study
only explained 11.4% of the variance in the positive patient safety culture
(Nagelkerke R2 = 0.114, p < 0.001). Our finding is similar to that of Alqattan et al.
(2018), but the variance is lower than that of other studies (Kumbi, Hussen, Abate
Lette, & Morka, 2020; Wami et al., 2016). Perhaps the R2 could have been increased
if we had included more predicted variables in this study. Several factors in previous
studies with high R2 are worth considering for inclusion in our study. The most
common factor is the number of events reported by the respondents (Alswat et al.,
2017; Kumbi et al., 2020; Mahrous, 2018; Samsuri et al., 2015). The details
regarding the implementation of an incident reporting system are also crucial
(Albalawi, Kidd, & Cowey, 2020; El-Jardali et al., 2011; Kumbi et al., 2020; Wami et

347

al., 2016). It is also beneficial to obtain input on whether staff are exposed to
information on patient safety during their initial education (Brasaite et al., 2016).

LIMITATIONS

Few limitations were noted in this study. First, our study's data were only collected
from a cluster hospital; our state has two other cluster hospitals located in the central
and southern regions of Kedah. However, we consider that our study's findings
provide a reasonably representative view of the patient safety culture that can be
expected in the other two cluster hospitals in Kedah, as their settings were identical
to those in our cluster. Another drawback is that we did not explore the connection
between patient safety culture and the number of events reported by respondents
and the patient outcome. Further research is required to identify the complicated
relationship between patient safety-culture and incident reporting system, the
number of reporting, patient outcomes, and how the data produced can be translated
into action and learning points. The findings are crucial and can guide us in
interventions and improvements to create a safe healthcare system and reduce
adverse medical outcomes.

The use of a questionnaire to evaluate safety culture or a particular safety
environment plays an essential role in planning the evaluation of an institution's
safety culture. Although a useful tool, SAQ has its limitation; it assesses staff’s
beliefs regarding the safety culture, rather than their real safety behavior (Alqahtani
& Evley, 2020). Notably, SAQ tests the current attitude regarding patient safety;
however, there may be differences between attitudes and actual practice. Therefore,
to explore the dimensions that influence patient safety in more detail, SAQ should
be combined with qualitative methods such as peer observation, group discussions,
analysis of organization’s incident history, and audits of the safety management
system (Alqattan et al., 2018; Hays & Singh, 2011; Poley et al., 2011). A wide gap
in research remains regarding how data obtained from different methods are related
and how to combine them to get a complete safety culture view. Despite these
limitations, we believe this research offers useful insight into our organizations’
baseline patient safety culture.

CONCLUSIONS

Overall, only a minority of the healthcare professionals at our cluster hospital have
a positive patient-safety culture (SAQ score ≥ 75%), which is far below the
international benchmarking standard. Attention should be paid to most of the safety
culture dimensions: working conditions, perception of management, safety climate,
teamwork climate, and stress recognition. Although the mean scores of the

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dimensions were mostly higher than the international standards, no dimension
reached the 75% minimum score to be recognized as an area of strength. The
significant findings include employees’ frustration with work environment quality and
logistics, particularly staffing levels in the clinical area.

RECOMMENDATIONS

There is much room for improvement in communication regarding patient safety
issues and errors, indicating that the organization’s existing culture is not reliable
and encouraging toward patient safety culture and incident reporting. Staffs were
also overly accustomed to busy work schedules and heavy workloads; thus, they did
not recognize the impact of stress on their work performance and patient safety. Staff
members should admit that stress, high workload, and sleep deprivation are among
the causes of reduced job performance and increased risk of medical errors. Despite
that, most respondents expressed satisfaction with their job; this presents an
opportunity, as those with higher job satisfaction are more likely to be actively
involved in accepting and implementing future quality-enhancement strategies.

Meanwhile, management commitment towards patient safety-improvement activities
is vital in nurturing healthcare professionals’ positive culture. Patient safety training
and the incident reporting system are two critical factors that should be emphasized
to improve patient safety culture. Organizations should consider and implement a
non-punitive and instructive incident reporting system as an instrument that can
strengthen the patient safety

ACKNOWLEDGEMENTS

We would like to express our gratitude to the Hospital Directors of the hospitals; Dr
Zaiton binti Udin, Dr Farozy Faizah Fazil and Dr Syed Satahkatullah for the
opportunities to conduct this study at their centre, and Dr Nukman bin Hussain and
Dr Firdaus bin Yusof for their assistance in data collection.

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CABARAN PETUGAS KESIHATAN DALAM PENGURUSAN
BANDUAN POSITIF COVID-19 DI PUSAT KUARANTIN DAN
RAWATAN COVID 19 (PKRC) PENJARA ALOR SETAR (KLUSTER

TEMBOK)

Norhasmaliza MN, Dr Mohd Fikri MF, Dr Siti Salma MS, PPP Wan Rashdan
WO, PJ Norrozaini , PPP Md Nasiron Y, Norulhadlyza AR

Bahagian Perubatan Jabatan Kesihatan Negeri Kedah

ABSTRAK
Pusat Kuarantin dan Rawatan Covid 19 (PKRC) Penjara Alor Setar diwujudkan pada
1 Oktober 2020 sehingga 31 Oktober 2020 bagi membendung penularan Covid-19
di kalangan banduan. PKRC ini juga bertujuan bagi mengurangkan beban hospital
dalam tempoh pandemik Covid-19. Perancangan rapi dibuat oleh petugas PKRC,
JKN Kedah dengan mengadakan bilik gerakan, menyusun struktur operasi yang
melibatkan petugas kesihatan serta ubahsuai blok banduan untuk dijadikan blok
rawatan bagi tujuan pengasingan kes positif Covid-19. Pengurusan rawatan pesakit
melibatkan proses saringan, pengesanan, pengasingan, rawatan, rujukan dan
pemantauan pesakit yang berterusan. Petugas kesihatan di bilik gerakan dan di
lapangan berhadapan dengan pelbagai cabaran bagi mencapai matlamat
penubuhan PKRC. Beberapa cabaran yang dikenalpasti antaranya adalah
kesukaran membuat pengasingan berdasarkan kategori jenayah disebabkan ruang
yang terhad, mendapatkan maklumat dan butiran lengkap pesakit banduan serta
keselamatan anggota disebabkan jumlah warden yang semakin berkurangan.
PKRC ini telah mencapai matlamat bagi mengelakkan penularan wabak di kalangan
banduan. Sebanyak 40% banduan tidak mendapat jangkitan Covid-19 dan 99.9%
banduan pulih dari Covid-19. Semangat kerja berpasukan dan profesionalisme di
kalangan petugas kesihatan dalam merancang dan menangani cabaran-cabaran
sepanjang pengoperasian PKRC Penjara Alor Setar telah membuahkan hasil dalam
memelihara nilai nyawa individu tanpa mengira latar belakang serta dapat
mengelakkan penularan jangkitan dalam komuniti.

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PENGENALAN

Pengurusan kes Covid 19 merupakan aspek penting dalam membendung penularan
wabak penyakit daripada menjadi diluar kawalan. Negeri Kedah juga turut terkesan
dengan wabak yang melanda Malaysia bermula di awal tahun 2020. Berikutan
peningkatan kes penularan COVID 19 di daerah Kota Setar, Perintah Kawalan
Pergerakan Diperketatkan (PKPD) telah dilaksanakan di daerah Kota Setar bermula
11 September sehingga 25 September 2020. Bahagian Perubatan JKN Kedah
menjangkakan kes positif COVID 19 akan berlaku peningkatan mendadak. Kapasiti
wad isolasi untuk negeri Kedah di Hospital Alor Setar hanya memuatkan 206 katil.
Pada ketika itu, hampir 50% katil telah digunakan.

Pada Oktober 2020, Negeri Kedah telah mula menerima kes banduan positif di
Penjara Alor Setar. Susulan daripada pengesanan kes positif pertama di penjara
Alor Setar dan peningkatan kes selepas kes tersebut, Kluster Tembok telah
didaftarkan sebagai kluster baru bagi negeri Kedah. Bahagian Perubatan Negeri
Kedah telah mencadangkan fasiliti Penjara sebagai Pusat Kuarantin dan Rawatan
Covid 19 (PKRC). PKRC di Penjara diwujudkan mengambil kira keselamatan umum
dan bilangan kes yang dijangka tinggi dengan kepadatan hospital untuk
menampung pesakit. PKRC Penjara Alor Setar telah bermula beroperasi pada 1
Oktober 2020 sehingga 31 Oktober 2020.

OBJEKTIF

Fasiliti pusat kuarantin dan rawatan diwujudkan bertujuan bagi menempatkan
banduan Penjara Alor Setar yang positif COVID-19, yang tidak bergejala atau
bergejala ringan.

Objektif Khusus
 Membuat pengesanan awal banduan banduan yang positif Covid-19
 Mengasingkan banduan yang positif Covid-19 berdasarkan screening/swab
test bagi menentukan kategori klinikal pesakit
 Memantau gejala harian pesakit bagi tujuan rawatan di hospital
 Memastikan pesakit mendapatkan rawatan segera sekiranya ada kes-kes
tenat.

PERANCANGAN AWAL

Bagi membolehkan PKRC beroperasi dengan teratur dan sistematik, satu
perancangan yang melibatkan:

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A- Mewujudkan struktur operasi dan carta organisasi yang terdiri daripada pegawai
perubatan, paramedik, dan kakitangan sokongan perubatan yang berkaitan beserta
pegawai penjara/warden
B- Mengadakan Bilik Gerakan
C- Susun atur semula Blok Banduan bagi tujuan pengasingan dan rawatan pesakit
D- Perancangan perawatan pesakit

A. PERANCANGAN SUMBER BAGI PENGOPERASIAN

1. Sumber Manusia
Rajah 1 menunjukkan carta organisasi PKRC

2. Keperluan Petugas Di PKRC
Jadual 1 menunjukkan senarai keperluan petugas di PKRC. Jadual tugas rawatan dibuat
mengikut 3 Shif. Manakala mobilisasi anggota dijalankan secara berperingkat mengikut
jumlah pesakit banduan yang positif. Mobilisasi bagi pegawai perubatan hanya melibatkan
pegawai perubatan di dalam Negeri Kedah. Manakala, mobilisasi bagi JT dan PPP
melibatkan negeri di luar Negeri Kedah.

Jadual 1: Senarai keperluan petugas di PKRC

Perkara Bilangan Anggota
Petugas Jabatan Kesihatan Negeri (Admin) 13
Pegawai Perubatan 19
Jururawat Terlatih Kawalan Infeksi 03
Jururawat Terlatih 30
Penolong Pegawai Perubatan 11
Pembantu Perawatan Kesihatan 03
Juru-X-Ray (pada setiap shif) 03

3. Kawalan Infeksi
Jururawat Terlatih Kawalan Infeksi dilantik bagi memantau proses kerja perawatan
pesakit terutamanya berkaitan pematuhan pada SOP bagi mengelakkan jangkitan
silang, pemakaian PPE serta pegawai perhubungan antara petugas pengursan bilik
gerakan dan Petugas Kesihatan di lapangan.
Skop Tugas merangkumi:
 Pemantauan Donning / Doffing
 Pengurusan pembuangan sisa klinikal
 Sanitasi peralatan perubatan yang digunakan semasa rawatan

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Rajah 1: Carta Organisasi PKRC Penjara

4. Aset Peralatan Perubatan / Bukan Perubatan
Keperluan peralatan perubatan diperoleh daripada beberapa hospital di Negeri
Kedah, terutamanya Hospital Sultanah Bahiyah, HSB bagi melancarkan
perkhidmatan yang disediakan di PKRC. Bahagian Perubatan, JKN Kedah telah
menyediakan peralatan bukan perubatan.

5. Alatan Pakai Buang (Consumables)
Peralatan Alat pakai buang disediakan oleh Bahagian Farmasi Hospital Sultanah
Bahiyah. Pengurusan, Pemesanan dan pengambilan dibuat oleh Bilik Gerakan
PKRC

6. Logistic – Transport / Clinical Waste / Food
Kemudahan pengangkutan disediakan dimana terdapat 1 Bas dan 2 Kenderaan
Jabatan bagi tujuan pengangkutan petugas pergi dan balik ke PKRC. Ini adalah
disebabkan oleh kedudukan logistik dalaman penjara dan keselamatan anggota
petugas memerlukan penghantaran petugas dari bilik Gerakan PKRC Penjara ke
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Blok Banduan.Pengambilan Consumables di HSB juga dibuat oleh kenderaan
jabatan.

7. Perkhidmatan Sokongan – Perkhidmatan X-Ray, Farmasi, Edgenta, Rekod
PKRC juga menyediakan perkhidmatan X-Ray sekiranya terdapat keperluan
penggunaan bagi menentukan kategori klinikal pesakit. Ubat-ubatan bagi
penggunaan pesakit banduan dan petugas telah disediakan oleh Bahagian Farmasi
HSB. Sementara itu, pengurusan sisa klinikal dan linen diuruskan oleh pihak
Edgenta Hospital Sultanah Bahiyah. Unit Rekod, Bahagian Perubatan JKN Kedah
telah membantu dalam pengurusan rekod dan data serta maklumat pengurusan
pesakit.

B. PENUBUHAN BILIK GERAKAN

Sejajar dengan perkhidmatan yang disediakan, terdapat keperluan untuk
mewujudkan Bilik Gerakan bagi memudahkan prose kerja harian petugas di PKRC.
Bilik Gerakan berfungsi sebagai:

1- Menempatkan semua anggota yang bertugas
2- Tempat bagi anggota melapor diri setiap hari sebelum menjalankan tugas dan

pada ketika kali pertama datang ke PKRC
3- Pengumpulan dan catatan data dan rekod pesakit dibuat di bilik gerakan
4- Sebarang perjumpaan dan mesyuarat diadakan di bilik gerakan
5- Stor simpanan peralatan / consumables
6- Bilik rehat dan tempat makanan bagi anggota disediakan di Kawasan bilik

Gerakan

Bilik Gerakan PKRC telah dibahagikan kepada
1- Ruang pentadbiran
2- Ruang anggota untuk merekodkan kad rawatan harian
3- Ruang simpanan fail
4- Ruang simpanan peralatan (perubatan/bukan perubatan)
5- Ruang makan
6- Ruang bilik rehat petugas kesihatan

C. SUSUN ATUR DALAM BLOK BANDUAN BAGI TUJUAN RAWATAN

Blok banduan penjara Alor Setar terdiri daripada Blok Utama iaitu Blok Lelaki dan
Blok Wanita. Manakala di dalam Blok Utama terdapat beberapa blok yang berbeza
dari segi saiz dan kapasiti penghuni yang boleh ditempatkan. Pengurusan penjara

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menempatkan banduan didalam blok-blok tersebut yang terdapat di Blok Utama
dibawah kategori jenayah-jenayah yang berbeza.

Walaubagaimanapun, bagi memenuhi keperluan rawatan blok-blok tersebut
terpaksa diubahsuai dan tiada lagi perbezaan kategori jenayah tersebut. Ini
menjadikan cabaran kepada petugas pihak KKM dan pihak penjara sendiri. Pada
peringkat awal, hanya terdapat beberapa banduan yang positif, oleh sebab itu hanya
beberapa blok sahaja di Blok Utama digunakan bagi tujuan pengasingan banduan
yang telah disahkan positif

Pada minggu kedua bilangan kes banduan yang positif bertambah, beberapa blok
baru telah dibuka bagi menempatkan banduan yang baru disahkan positif. Proses
pembukaan blok baru bagi menempatkan banduan positif berlaku secara berterusan
disebabkan keputusan ujian saringan Covid19 diperolehi secara berperingkat.
Jumlah keseluruhan banduan adalah 1885. Sebanyak 1131 bilangan banduan
disahkan positif sepanjang tempoh PKRC Penjara Alor Setar diwujudkan.

Bagi tujuan kawalan infeksi, beberapa ruang diadakan sepanjang tempoh
penggunaan blok banduan tersebut:

1- Ruang laluan bersih / kotor berasingan
2- Ruang menempatkan sisa klinikal
3- Bilik mandi anggota
4- Ruang pemakaian PPE bagi anggota petugas
5- Ruang pemeriksaan di dalam blok
6- Ruang Simpanan Consumables / PPE

D. PERANCANGAN PERAWATAN PESAKIT

Saringan
Saringan dijalankan oleh Unit Kecemasan Hospital Sultanah Bahiyah yang terdiri
daripada beberapa kumpulan mengikut shif. Jadual dan susun atur kerja
dikendalikan oleh Ketua Jabatan unit Kecemasan HSB. Semua maklumat dan data
dikongsi bersama pihak Penjara dan bilik Gerakan bagi tujuan pengesanan dan
pengasingan banduan yang positif. Saringan dibuat di Blok Pra-Bebas. Semua
keputusan positif yang diperolehi setiap pagi dari CPRC disalurkan ke Bilik Gerakan
bagi tujuan pengasingan.

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Pengasingan
Bilik Gerakan menerima bilangan dan senarai nama banduan yang positif dari CPRC
negeri. Pengasingan kemudiannya dijalankan oleh anggota yang terlibat dan
banduan positif telah dipakaikan gelang pink bagi tujuan pengecaman. Banduan
yang disahkan positif ditempatkan di blok penjara yang ditentukan oleh warden
penjara hasil perbincangan bersama bilik Gerakan.
Cabaran semasa pengasingan adalah kebergantungan kepada pihak penjara
disebabkan banduan yang berkebolehan menukar gelang di tangan. Penempatan
banduan juga adalah berdasarkan jumlah kapasiti muatan di sesebuah blok penjara
dan senarai nama banduan yang positif bertambah setiap hari. Masih terdapat
banduan yang tidak bergejala dan ujian saringan adalah negatif dan perlu
diasingkan dari banduan positif. Penggunaan blok adalah terhad bagi memenuhi
keperluan pengasingan. Kita juga berhadapan dengan isu pengasingan banduan
yang dikategorikan jenayah berat dan ringan yang terpaksa ditempatkan di blok
yang sama.

Pemantauan Dan Pemeriksaan Harian
Semua banduan yang disahkan positif dan dimasukkan ke blok pengasingan adalah
di bawah pemantauan bilik Gerakan. PKRC hanya menempatkan banduan dengan
kategori klinikal I & II Covid-19 sahaja. Pegawai perubatan yang bertugas pada
setiap shif akan memeriksa dan merekodkan hasil pemeriksaan di dalam fail pesakit
di blok pengasingan. Sekiranya terdapat keperluan untuk perkhidmatan X-Ray, juru-
xray akan dipanggil.

Setiap banduan akan dilihat oleh pegawai perubatan dan paramedik sekurang-
kurangnya sehari sekali. Pegawai perubatan juga bertugas atas panggilan bagi
tujuan kecemasan. Semua petugas-petugas kesihatan dikehendaki patuh pada
SOP kawalan infeksi bagi mengelakkan infeksi jangkitan silang. Pengurusan bilik
Gerakan mengatur jadual pegawai perubatan dan paramedik. Sekiranya berlaku
kecemasan dan perlu rujukan segera, iaitu berlaku perubahan pada kategori klinikal
pesakit, kategori III dan ke atas, pegawai perubatan atas panggilan yang bertugas
akan memeriksa banduan dan membuat rujukan ke HSB.

Ciri Demografik
Jadual 2 menunjukkan bilangan banduan yang dipantau oleh PKRC. Jumlah
keseluhan adalah seramai 1885. Dari jumlah ini 1131 (60%) adalah banduan positif
manakala 754 (40%) adalah negatif. Jadual 3 menunjukkan ciri sosidemografi bagi
banduan positif COVID-19.

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Keberkesanan Pengwujudan PKRC Penjara Alor Setar
 Penggunaan bangunan sedia ada bagi menampung bilangan banduan sedia ada,

tiada sebarang peruntukan khas bagi penyediaan bangunan.
 Penggunaan khidmat pegawai penjara sedia ada (warden) yang telah dilatih

untuk menjaga banduan dalam membuat pemantauan. Isu keselamatan dapat
ditangani bagi mengelakkan sebarang perkara tidak diingini berlaku.
 Mengurangkan beban hospital dengan pertambahan mendadak bilangan pesakit
Covid-19 terutamanya dalam kalangan pesakit banduan.
 Perlaksanaan sistem pengurusan data maklumat pesakit dapat dibuat dalam
masa yang singkat bagi memastikan rekod pesakit dibuat secara sistematik dan
kemasukan data pesakit dapat dilakukan oleh semua peringkat

Limitasi Dan Cabaran
 Kita menghadapi kesukaran membuat pengasingan berdasarkan kategori

jenayah disebabkan ruang yang terhad
 Terdapat banduan yang gagal memberikan maklumat lengkap berkaitan

maklumat peribadi diri
 Kesukaran mengenalpasti identiti banduan sekiranya banduan tersebut

memalsukan maklumat peribadi diri semasa pemeriksaan dibuat. Petugas
Kesihatan berhadapan dengan jumlah banduan yang ramai, mereka hanya
bergantung kepada warden bagi memanggil banduan untuk diperiksa.
 Walaupun berada di kawasan yang dikawal oleh warden, namun ratio warden
dengan jumlah banduan adalah terlalu besar, isu keselamatan petugas kesihatan
tidak dapat dijamin sepenuhnya. Ini ditambah pula dengan jumlah warden yang
terpaksa menjalani kuarantin akibat penularan Covid-19 di kawasan Penjara Alor
Setar.

Jadual 2: Bilangan banduan di bawah pemantauan PKRC

Perkara Bilangan Peratusan (%)

Jumlah keseluruhan 1885 -

banduan 40%
60%
Banduan negatif 754

Banduan positif covid 1131

Jadual 3: Ciri Sosiodemografik untuk banduan Positif Covid-19 (N=1131)

Perkara Bilangan Peratusan (%)

Warganagera

Warganegara 1066 94%

Bukan Warganegara 65 6%

Mempunyai co-morbidities 29 3%

Jantina

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Lelaki 1130 99.9%

Perempuan 1 0.1%

Kategori Umur

18-40 733 70%

41-60 302 29%

>60 7 1%

Tiada maklumat 89

Rawatan (rujuk/discaj/meninggal)

Diirujuk ke HSB 84 7.4%

Discaj semula ke penjara 83 98.8%

Meninggal dunia di ICU 1 1.2%

*Limitasi Data Demografik Terdapat 89 data banduan tidak mempunyai maklumat diri yang lengkap

dan data tersebut adalah diluar kawalan pihak pengurusan bilik gerakan.

KESIMPULAN

Matlamat Kementerian Kesihatan Malaysia (KKM) adalah untuk memberi
kemudahan dan perkhidmatan kesihatan yang berkualiti pada semua individu tidak
mengira latar belakang bagi mana-mana individu tersebut. Setiap nyawa adalah
sangat berharga. Pusat Kuarantin dan Rawatan Covid 19 (PKRC) Penjara Alor
Setar telah berjaya diwujudkan bagi menempatkan banduan yang positif Covid-19
(kategori klinikal I & II) dengan 99.9% banduan sembuh dan pulih. Hanya terdapat
seorang banduan yang dimaklumkan telah meninggal dunia semasa berada di ICU,
Hospital Sultanah Bahiyah. Objektif pengasingan awal telah berjaya dilaksanakan
bagi mengelakkan daripada semua banduan dijangkiti Covid-19, iaitu sebanyak 754
banduan yang masih negatif (40%).

Hasil ujian saringan dan pemantauan harian yang berterusan membolehkan
banduan dengan kategori klinikal I & II dipantau di Blok Penjara Alor Setar. Manakala
bagi banduan dengan kategori klinikal III dan ke atas, dapat dirujuk ke Hospital
Sultanah Bahiyah dengan kadar segera bagi mengelakkan komplikasi yang tidak
diingini yang boleh menyebabkan kematian di dalam Penjara Alor Setar.

PKRC ini juga telah berjaya melaksanakan tugas yang diamanahkan secara
professional dengan penuh keprihatinan terhadap banduan selaku pesakit di PKRC
tersebut, serta semangat berpasukan dan sikap bertanggungjawab di kalangan
petugas kesihatan dan juga di antara Jabatan Kesihatan Negeri Kedah dan Jabatan
Penjara Alor Setar. Perancangan teliti dan usaha berterusan sepanjang PKRC
Penjara Alor Setar beroperasi telah membuahkan hasil dalam memelihara nilai
nyawa individu tanpa mengira latar belakang serta dapat mengelakkan penularan
jangkitan dalam komuniti.

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MAKESHIFT TREATMENT CENTRE PENJARA POKOK SENA
MEMBENDUNG PENULARAN WABAK COVID-19 BAGI KLUSTER

TEMBOK DI NEGERI KEDAH

Hairil S.I1, Huzaifah M.N.1*, Noorhaslinda Y1*

1Bahagian Perubatan Jabatan Kesihatan Negeri Kedah, 05400, Alor Setar, Kedah.

_______________________________________________________________

PENGENALAN

Pembukaan Makeshift Treatment Centre (MTC) di Penjara Pokok Sena (PPS)
Kedah adalah satu projek rintis yang pertama kali dilaksanakan sebagai hospital
medan bagi memberi rawatan dan berfungsi sebagai pusat kuarantin bagi pesakit
COVID-19 dalam kalangan banduan dan Orang Kena Tahan (OKT). MTC adalah
hospital medan pertama yang berjaya dibina dalam kawasan penjara di Malaysia.
Objektif penubuhan MTC adalah untuk mewujudkan rawatan berpusat bagi banduan
positif di Negeri Kedah. Selain itu, MTC diwujudkan untuk memberi rawatan kepada
pesakit COVID-19 dalam kalangan banduan kategori 1 hingga 4.

Inisiatif ini bermula pada 30 September 2020 apabila terdapat seorang banduan di
Penjara Alor Setar yang dikesan positif COVID-19 dan telah menjangkiti dua
banduan yang lain sehingga menyebabkan wujudnya satu kluster baharu di negeri
Kedah iaitu Kluster Tembok. Kluster ini telah memberi impak besar dalam
pengurusan kesihatan dan memberi bebanan kepada fasiliti kesihatan terutama
hospital di negeri Kedah. Ini kerana berlaku peningkatan kes di kalangan banduan,
warden penjara, ahli keluarga dan merebak ke seluruh penjara di sekitar negeri
Kedah seperti Penjara Sungai Petani dan Penjara Pokok Sena dan Depo Tahanan
Imigresen Belantik, Sik, Kedah.

Hal ini menyebabkan kesesakan di hospital negeri Kedah disebabkan kekurangan
katil hospital bagi memberi rawatan kepada pesakit COVID-19 dalam kalangan
banduan di negeri Kedah. Selain itu, pesakit COVID-19 dalam kalangan banduan
perlu dibuat pengasingan dengan pesakit COVID-19 dalam kalangan orang awam
di atas faktor keselamatan. Hal ini bagi mengelakkan banduan berkenaan melarikan
diri semasa mendapat rawatan dan menjalani tempoh kuarantin.

Tan Sri Dato’ Seri Dr Noor Hisham Abdullah melalui hantaran media sosialnya pada
21 Oktober 2020 berkata fokus utama penubuhan MTC adalah sebagai pusat

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rawatan atau hospital medan bagi Orang Kena Tahan (OKT) dari pusat tahanan /
penjara di bahagian utara Malaysia yang disahkan positif COVID-19 yang sebelum
ini telah menerima rawatan di Hospital Sultanah Bahiyah dan Hospital Alor Setar.
PELANTIKAN JAWATANKUASA PENGELOLA
Sebelum penubuhan MTC, satu jawatankuasa telah dibentuk bagi pengoperasian
satu pusat kuarantin COVID-19 berisiko rendah yang dikenali sebagai Low Risk
Covid Centre (LRCC) Penjara Pokok Sena. Satu perbincangan khas telah diadakan
di peringkat Jabatan Kesihatan Negeri Kedah. Dr Noorhaslinda bt Yeop telah dilantik
sebagai Pengarah LRCC PPS dan dibantu oleh Dr Huzaifah bin Md Nor bagi
menyelaras gerak kerja dan mengatur pergerakan anggota kesihatan untuk
dimobilisasi ke sana. Selain itu, Jabatan Kecemasan dan Trauma Hospital Sultanah
Bahiyah juga telah memberi pandangan tentang prosedur pengoperasian hospital
medan bagi tujuan perawatan Covid-19. Melalui perbincangan berterusan dengan
pihak KKM dan Jabatan Penjara Malaysia, Jabatan Kesihatan Negeri Kedah telah
memutuskan supaya Low Risk Covid Centre (LRCC) ditubuhkan dan beroperasi di
Penjara Pokok Sena bagi merawat pesakit COVID-19 di dalam bangunan penjara
sedia ada.

Rajah 1: Carta Organisasi MTC dan PKRC Penjara Pokok Sena

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PENUBUHAN LOW RISK COVID CENTRE (LRCC) PENJARA POKOK SENA

Penjara Pokok Sena mempunyai seramai 3544 orang banduan yang diasingkan
mengikut sel dan seramai 550 staf atau warden yang ditugaskan untuk menjaga
banduan berkenaan. Selepas 60 orang banduan dijangkiti COVID-19, keadaan ini
menyebabkan kerisauan perebakan kluster di penjara ini. Exco Kesihatan Negeri
Kedah, Datuk Dr Mohd Hayati Othman berkata situasi kesesakan dan kepadatan
banduan dan tahanan yang menghuni penjara ini menjadi penyebab kenaikan kes
di penjara Pokok Sena dan menyumbang kepada gelombang kedua pandemik
COVID-19 di negeri ini. Dengan tercetusnya Kluster Tembok di Penjara Alor Setar
dan bimbang akan merebak ke Penjara Pokok Sena, JKN Kedah telah mengatur
langkah ke arah pembukaan satu lagi LRCC di Penjara Pokok Sena. Pada 6 Oktober
2020, tiga orang wakil daripada JKN Kedah telah ke Penjara Pokok Sena untuk
bermesyuarat bersama Pengarah Penjara Pokok Sena bagi membincangkan
penubuhan LRCC berkenaan.

Ketua Jabatan Kecemasan dan Trauma serta Pakar Kecemasan Hospital Sultanah
Bahiyah juga terlibat dalam perbincangan tersebut. Mengikut garis panduan yang
ditetapkan oleh Kementerian Kesihatan Malaysia, banduan yang disahkan positif
COVID-19 perlu diberikan rawatan dan diasingkan daripada banduan lain.
Sehubungan dengan itu, satu lawatan tapak telah dijalankan selepas mesyuarat
bagi mengenalpasti lokasi dan tapak sesuai untuk membina khemah donning,
doffing dan khemah pemeriksaan dan rawatan pesakit COVID-19 di luar blok
pengasingan dan kuarantin di Penjara Pokok Sena.

Rajah 2: Kawasan Donning petugas sebelum memulakan tugasan merawat
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Rajah 3: Khemah dan Pemeriksaan Harian dan Rawatan Pesakit COVID-19

Pada 7 Oktober 2020, seorang Penyelia Jururawat dan seorang Ketua Jururawat
dimobilisasi ke LRCC PPS. Selain itu, 5 orang pegawai perubatan, 10 orang
penolong pegawai perubatan, 2 orang jururawat terlatih dan seorang jururawat Unit
Kawalan Infeksi (ICN) dan seorang Pembantu Perawatan Kesihatan (PPK) telah
diarah bertugas dan menjadi pasukan perubatan perintis dalam memberi rawatan
kepada pesakit COVID-19 di Penjara Pokok Sena. Dengan bantuan dan tunjuk ajar
daripada Pakar Perubatan Kecemasan daripada Hospital Sultanah Bahiyah, senarai
banduan yang dikesan positif disaring dan diasingkan dari blok and sel banduan
yang lain. Pada masa yang sama, SOP perawatan pesakit, cara pemakaian PPE
dan teknik doffing yang betul diajar kepada petugas kesihatan perintis yang bertugas
di LRCC PPS. Pendaftaran dan rekod peribadi pesakit dilaksanakan secara manual
sebelum satu sistem pengurusan pesakit secara online dijana oleh unit ICT Jabatan
Kesihatan Negeri Kedah.

CADANGAN PENUBUHAN MAKESHIFT TREATMENT CENTRE (MTC) DENGAN
PENGLIBATAN ATM DAN AGENSI KERAJAAN LAIN

Dengan peningkatan jumlah banduan yang didapati positif COVID-19 saban hari,
keadaan ini telah menyebabkan masalah kesesakan di wad COVID-19 Hospital
Sultanah Bahiyah dan Hospital Alor Setar yang memberikan fokus kepada rawatan
pesakit COVID-19 kategori 3 dan 4. Selain itu, seorang pengawal atau warden
penjara perlu mengiringi setiap banduan dalam tempoh pengasingan dan rawatan.
Hal ini juga memberi tekanan kepada pihak Jabatan Penjara Malaysia untuk

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mengiringi banduan berkenaan dan terdapat juga warden penjara yang terpaksa
dikuarantin kerana didapati positif dan menjadi kontak rapat kepada pesakit COVID-
19.

Rajah 4: Pasukan ATM KOR Kesihatan Diraja (KDD) yang terliat di MTC
Menteri Kanan (Keselamatan) Datuk Seri Ismail Sabri Yaakob telah mengumumkan
pelaksanaan Perintah Kawalan Pergerakan Diperketatkan (PKPD) di Penjara Pokok
Sena, Kedah pada 11 Oktober 2020 dan kemudian dilanjutkan selama 14 hari lagi
sehingga 7 November 2020. Lanjutan itu mengambil kira cadangan Majlis
Keselamatan Negara (MKN) dan nasihat KKM berikutan seramai 128 kakitangan
dan ahli keluarga serta banduan di Penjara Pokok Sena disahkan positif COVID-19
bagi Kluster Tembok. Pengarah Penjara Pokok Sena, Timbalan Komisioner Jamil
Razif Kassim berkata, daripada jumlah itu, terdapat 10 kes melibatkan kakitangan
penjara dan tujuh lagi adalah ahli keluarga mereka. Hal ini menyulitkan kakitangan
dan membataskan pergerakan keluar masuk anggota serta pegawai untuk bertugas
di PPS.
Mesyuarat task force bersama agensi kerajaan dan swasta telah bersetuju dengan
penubuhan hospital medan sementara bagi merawat pesakit COVID-19 di kalangan
banduan yang dikenali sebagai Makeshift Treatment Centre atau MTC. Oleh kerana
hospital medan lebih sinonim dengan penglibatan, kepakaran dan aset ketenteraan,
pasukan Angkatan Tentera Malaysia (ATM) dikerahkan bagi membantu KKM dalam
cadangan penubuhan MTC ini. Pasukan perubatan ini diketuai oleh Pakar
Perubatan Kesihatan Awam, Jabatan Perubatan Tentera, Hospital Angkatan

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Tentera Tuanku Mizan, Kolonel (Dr) Mohd Arshil Moideen, Penolong Ketua
Pengarah Perkhidmatan Kesihatan 2 Div, Leftenan Kolonel (Dr) Faira Rosmarina
Mohd Rustam dan Pegawai Pemerintah B Komp 2 Bn Ubat, Kapten (Dr) Muhammad
Asyraf Khairul Hasni. Selain itu, seramai 2 pegawai perubatan dan 5 paramedik Kor
Kesihatan Diraja Malaysia (KDD) ditugaskan berkhidmat dan dimobilisasi ke MTC
PPS.

Melalui Mesyuarat Keselamatan Dan Kesihatan Peringkat Kerajaan Negeri Kedah,
Kerajaan Negeri bersetuju untuk bekerjasama membantu dalam penubuhan MTC di
dalam kawasan Penjara Pokok Sena. Agensi peringkat persekutuan, negeri dan
swasta serta NGO menghulurkan tangan dalam membantu JKNK membina hospital
medan ini. Setiap agensi membantu menyumbangkan kepakaran dan aset masing
masing seperti NADMA, JKR, SUK, SADA, TM, SAPURA, MBAS, PDRM, BOMBA,
UEM EDGENTA, dibantu dengan sumbangan katil dari NGO seperti Pertubuhan Tzu
Chi dan lain lain.

TRANSFORMASI DATARAN VOKASIONAL DAN INDUSTRI PPS KEPADA
MAKESHIFT TREATMENT CENTRE (MTC)

Lawatan tapak telah giat dilakukan oleh Pakar Perubatan Kesihatan Awam,
Angkatan Tentera Malaysia (ATM) bersama pegawai dari pelbagai agensi lain bagi
membuat penilaian yang tepat akan kesesuaian penubuhan hospital medan bagi
mengantikan fungsi LRCC. Satu kawasan dataran yang luas dan terletak
berhampiran dengan pintu masuk penjara telah dikenalpasti sebagai tapak hospital
medan iaitu bertempat di Dataran Vokasional dan Industri Penjara Pokok Sena.
Selain daripada dataran yang luas, kawasan ini dikelilingi blok bangunan yang
beroperasi sebagai bengkel latihan dan penghasilan kraftangan, bengkel jahitan,
bengkel pembuatan kicap dan bengkel pembuatan sabun. Pada ketika tercetusnya
kluster tembok, bengkel berkenaan tidak beroperasi kerana banduan-banduan
berkenaan telah diasingkan dalam blok tahanan masing masing bagi mengelakkan
jangkitan di kalangan penghuni penjara. Sehubungan dengan itu, blok Rotan dan
Blok Batik di Kompleks Vokasional dan Industri Penjara Pokok Sena telah dipilih
sebagai pusat rawatan dan isolasi banduan positif COVID-19 dan dataran tersebut
digunakan bagi mendirikan hospital medan ini.

Bagi membina hospital medan ini, seramai 4 pegawai dan 20 anggota lain lain
pangkat daripada Kompeni B, Batolian Kedua Perubatan (2 Bn Ubat) Kor Kesihatan
Diraja (KKD) telah diaturgerak bagi membantu kerja-kerja persiapan MTC.
Sebanyak 37 unit khemah didirikan di dataran berkenaan iaitu merangkumi 6 unit
Khemah Utilis 36 dari TM, 5 Unit Khemah PLKN, 1 unit Khemah Military Tent 6m x

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9m, 1 unit Military Tent 6m x 8m dan 1 unit Sun Tent with ending dan 3 unit Khemah
mandi dari B Coy 2 Bn Ubat.

Sebanyak 20 khemah yang disewa oleh pihak JKR telah digunakan sepenuhnya
sebagai koridor laluan yang menghubungkan antara 2 blok rawatan yang
disediakan. 2 buah unit khemah digunakan sebagai bilik operasi yang menempatkan
komputer, alat komunikasi GIRN dan monitor TV bagi CCTV yang diletakkan di
dalam blok rawatan. Sebuah khemah resusitasi bagi menempatkan dua buah katil
resus dan peralatan kecemasan telah ditempatkan di luar blok rawatan. Selain itu,
khemah stor PPE, linen bersih, farmasi bekalan ubat serta khemah makmal seperti
mesin ABG dan FBC telah diletakkan di sekitar kawasan dataran. 2 khemah juga
dijadikan sebagai bilik rehat petugas dan tempat donning sebelum merawat pesakit
di dalam blok rawatan. Setelah proses pemasangan khemah di Dataran Vokasional
dan Industri dilakukan, terdapat cabaran di mana khemah yang dipasang sangat
panas dan tidak sesuai diduduki staf kesihatan serta portable aircond yang
disediakan oleh pihak JKR Mekanikal tidak memenuhi kreteria dan menyebabkan
haba panas berkumpul di dalam khemah berkenaan. Oleh itu, JKR Mekanikal telah
diminta oleh pihak Kerajaan Negeri untuk menggantikan portable aircond berkuasa
tinggi dengan kuantiti yang lebih banyak bagi menyejukkan ruang di dalam khemah
berkenaan.

Rajah 5: Dataran Vokasional dan Industri PPS sebelum dan selepas pembinaan MTC

BENGKEL ROTAN DINAIK TARAF KEPADA WAD ROTAN

Semasa lawatan tapak di peringkat awal, sebuah bengkel batik yang terletak di
tingkat dua blok telah dikenalpasti untuk dijadikan wad rawatan COVID-19. Akan
tetapi, selepas penelitian dan perbincangan, bengkel batik didapati tidak sesuai
dijadikan wad rawatan kerana kemungkinan wujudnya kesukaran membawa turun
pesakit menggunakan tangga sekiranya berlaku kecemasan. Keadaan tangga yang

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curam dan sempit akan menyukarkan petugas kesihatan menurunkan pesakit
menggunakan stretcher.
Oleh itu, sebuah bengkel rotan yang terletak di tingkat lantai (ground floor) telah
dinaiktaraf sebagai wad rawatan dan kuarantin COVID-19 yang boleh menempatkan
100 katil mudah alih (portable bed). 2 katil bagi rawatan akut (acute bay) yang
lengkap dengan gas oksigen juga telah disediakan di dalam wad berkenaan. Selain
itu, satu ruang telah dijadikan sebagai bilik rawatan dan pemeriksaan yang
dilengkapi dengan mesin X-Ray, mesin vital sign, mesin ECG, tong oksigen dan
farmasi satelit serta kemudahan komputer riba bagi mengisi maklumat pesakit dalam
sistem ICT yang disediakan.

Rajah 6: Pelan Lantai Bengkel Rotan yang dijadikan wad rawatan COVID-19
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PENYEDIAAN PROSEDUR OPERASI STANDARD (SOP) DAN POLISI
KESELAMATAN MAKESHIFT TREATMENT CENTRE (MTC)

Satu SOP khusus pengoperasian Makeshift Treatment Centre (MTC) telah digubal
bagi tujuan pengoperasian sebuah hospital medan. Dengan menjadikan SOP
MAEPS Serdang sebagai panduan pengoperasian hospital medan, MTC PPS telah
menggubal dan mengubahsuai beberapa SOP agar dapat diselarikan dengan polisi
keselamatan yang ketat yang ditetapkan oleh Pihak Penjara Pokok Sena bertujuan
mengelakkan banduan melarikan diri dan membahayakan petugas kesihatan yang
bertugas di situ.

Sebagai contoh, bagi kemasukan petugas kesihatan untuk bekerja ke dalam
kawasan penjara, satu SOP keselamatan yang ketat telah ditetapkan oleh pihak
penjara. Petugas kesihatan tidak dibenarkan membawa telefon bimbit peribadi,
pendrive dan alat komunikasi yang lain ke dalam kawasan penjara. Alatan elektronik
dan komunikasi perlu disimpan dalam pigeon hole dan pemeriksaan badan
dilakukan sebelum dibenarkan masuk dalam kawasan penjara. Selain itu, bagi
memudahkan komunikasi secara terus, hanya telefon bimbit yang didaftarkan dan
mendapat kelulusan Pengarah Penjara Pokok Sena sahaja yang dibenarkan dibawa
masuk. Kawalan keselamatan yang ketat juga bertujuan mengelakkan gambar-
gambar yang sensitif dirakam di dalam kawasan penjara dan disebarkan kepada
umum.

Selain itu, prosedur kerja Unit Keselamatan Penjara (UKP) dan Trup Tindakan Cepat
(TTC) perlu diikuti setiap masa. Petugas kesihatan yang bertugas memberikan
rawatan kepada pesakit di dalam Wad Rotan perlu diiringi oleh UKP dan TTC pada
setiap masa. Petugas kesihatan dilarang melakukan prosedur bersendirian tanpa
pengawasan TTC dan UKP kerana bimbang dengan ancaman keselamatan dari
banduan yang boleh bertindak di luar jangkaan seterusnya boleh mencederakan
petugas kesihatan.

Selain itu, peralatan perubatan yang tajam seperti branula, jarum suntikan boleh
dijadikan sebagai senjata oleh banduan berkenaan untuk melarikan diri. Oleh itu,
dengan pematuhan SOP yang ditetapkan dapat menjamin keselamatan dan
memberi keselesaan kepada petugas kesihatan semasa merawat banduan yang
positif COVID-19. Ini kerana tahanan dan pesalah yang menjalani hukuman dalam
penjara terdiri daripada pelbagai kesalahan jenayah berat seperti mencuri, merogol,
kes dadah, merompak dan membunuh. Oleh itu, pengawasan yang ketat daripada
UKP dan TTC adalah penting pada setiap masa bagi mengelakan perkara yang tidak
diingini berlaku.

370

Rajah 7: Carta Alir Pemeriksaan Pesakit di MTC

PENGOPERASIAN MAKESHIFT TREATMENT CENTRE (MTC) PPS

Makeshift Treatment Centre memulakan operasi secara rasmi pada 22 Oktober
2020 selepas melalui beberapa siri latihan dan simulasi (dry run) yang dilakukan
dengan bantuan dan tunjuk ajar dari Dr Md. Anuar bin Abd Samad iaitu Pengarah
MAEPS 1.0 dan Kolonel (Dr) Mohd Arshil Moideen, Pakar Perubatan Kesihatan
Awam, Angkatan Tentera Malaysia.
Seramai 50 petugas kesihatan daripada seluruh semenanjung Malaysia telah
dimobilisasi ke MTC termasuk dari Kelantan, Terengganu, Pahang, Johor, Perak,
Pulau Pinang dan Putrajaya. Para petugas diberikan penginapan yang selesa di
Hotel Fuller, Alor Setar dan pengangkutan ke Penjara Pokok Sena juga diuruskan
oleh pihak Jabatan Kesihatan Negeri Kedah.

CABARAN DALAM PENGOPERASIAN MAKESHIFT TREATMENT CENTRE
(MTC) PPS

Walaupun MTC PPS telah sedia beroperasi dengan kapasiti maksimum iaitu 100
katil dengan kekuatan petugas kesihatan yang mencukupi, akan tetapi bilangan
kemasukan pesakit positif COVID-19 dalam kalangan banduan Penjara Pokok Sena

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semakin berkurangan. Bagi mengoptimumkan penggunaan katil di MTC, satu
mesyuarat dengan Pengarah Penjara Pokok Sena telah dilakukan dan mesyuarat
telah bersetuju untuk menerima kemasukan pesakit di kalangan banduan daripada
Penjara Sungai Petani serta tahanan dari Depo Tahanan Imigresen Belantik, Sik.
Selain itu, terdapat beberapa masalah yang berlaku sepanjang pengoperasian MTC
seperti berikut:

i. Khemah yang didirikan kerap rosak dan roboh apabila berlaku hujan lebat
dan angin lintang.

ii. Masalah sistem perpaipan dari penyaman udara yang kerap bocor di dalam
khemah rehat petugas kesihatan.

iii. Aset yang diterima terlalu banyak dan tiada penyelia aset perubatan yang
bertanggungjawab menyebabkan pengurusan aset tidak tersusun.

iv. Segelintir petugas mempunyai masalah disiplin yang menjejaskan
perkhidmatan kepada pesakit.

v. Fasiliti penjara yang tidak bersih dan berlaku pencemaran bau.

Beberapa strategi telah dilaksanakan bagi memperbaiki keadaan antaranya:
i. Berhubung dengan JKR Mekanikal untuk pembaikan masalah sistem
perpaipan dari penyaman udara.
ii. Pihak pengurusan melakukan tindakan tegas dan menamatkan petugas yang
bermasalah disiplin.
iii. Penyelia Penolong Pegawai Perubatan daripada Hospital Jitra telah
dimobilisasi ke MTC bagi menjaga asset perubatan.
iv. Ketua Jururawat sentiasa memantau persekitaran MTC dan bekerjasama
dengan pegawai penjara bagi tujuan pembersihan di kawasan sekitar.

PENUTUPAN MAKESHIFT TREATMENT CENTRE (MTC) PPS DAN
DITUKARFUNGSI KEPADA PUSAT KUARANTIN DAN RAWATAN COVID-19
(PKRC) PENJARA POKOK SENA

Setelah lebih dua bulan MTC beroperasi di Penjara Pokok Sena dan telah merawat
hampir 300 pesakit COVID-19 dalam kalangan banduan, akhirnya Mesyuarat
Pengurusan COVID-19 peringkat JKN Kedah telah memutuskan penutupan MTC
dan ditukarfungsi kepada Pusat Kuarantin Dan Rawatan COVID-19 (PKRC) Penjara
Pokok Sena bermula 1 Januari 2021. Ini kerana Kluster Tembok masih belum
ditamatkan dan banduan yang positif COVID-19 dalam kategori satu dan dua masih
memerlukan pemeriksaan dan rawatan oleh petugas kesihatan KKM di dalam
penjara. Sehubungan dengan itu, proses penutupan dan pemulangan aset
perubatan dan bukan perubatan telah dilakukan secara berperingkat.

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Bagi pengoperasian PKRC PPS, petugas kesihatan dikurangkan kepada 10 orang
sahaja termasuk tiga petugas di bahagian pengurusan, dua orang pegawai
perubatan, 3 orang paramedik dan seorang pembantu perawatan kesihatan yang
diketuai oleh Dr Huzaifah bin Md Nor selaku Pengarah PKRC PPS. PKRC PPS
beroperasi setiap hari bermula jam 8.00 pagi hingga 5.00 petang manakala selepas
waktu pejabat, penjagaan dan rawatan pesakit diambilalih oleh petugas kesihatan
dari pihak penjara. Selain daripada memberikan rawatan kepada pesakit, petugas
kesihatan KKM juga membantu pasukan kesihatan penjara melakukan saringan
RTK dan PCR kepada banduan pra bebas dan banduan yang bergejala selepas
melakukan pemeriksaan harian pesakit yang dikuarantin.

PENUTUP

Pada 1 Februari 2021, Kluster Tembok telah diisytiharkan tamat sepenuhnya
setelah berlarutan hampir 5 bulan. Kluster ini telah merekodkan 3169 kes positif
yang telah menjangkiti banduan dan ahli keluarga anggota penjara. Mengikut
pecahan, sebanyak 1772 kes melibatkan warganegara dan 1397 kes melibatkan
bukan warganegara. Sebanyak 6 kes kematian dicatatkan dalam kluster tersebut.
Kluster ini telah melibatkan dua buah negeri iaitu Kedah dan Perak manakala daerah
di negeri Kedah yang terlibat ialah Kota Setar, Baling, Kuala Muda, Kubang Pasu,
Padang Terap, Sik, Bandar Baharu, Kulim dan Pendang. Seterusnya merebak ke
Larut, Matang, Selama, Hilir Perak dan Kinta di negeri Perak. Sehubungan dengan
itu, PKRC PPS secara rasminya telah menamatkan operasi pada 7 April 2021. Kes-
kes positif Covid selepas tarikh berkenaan diuruskan dan dirawat oleh petugas
kesihatan penjara.

RUMUSAN

Dengan pengoperasian Low Risk COVID-19 Center (LRCC), MTC dan PKRC PPS
yang telah berlangsung selama hampir 7 bulan dan telah berjaya merawat hampir
2000 pesakit COVID-19 dalam kalangan banduan, ia telah dapat mengurangkan
kesesakan dan mengurangkan kebergantungan kepada fasiliti kesihatan di hospital
KKM di negeri Kedah. Selain itu, pembukaan hospital medan ini juga telah
membuktikan kerjasama yang erat dari pelbagai agensi kerajaan dan swasta serta
NGO yang mempunyai tujuan yang sama untuk membantu negara mengekang
penularan COVID-19 dalam masyarakat dan memberikan perawatan kesihatan
yang terbaik kepada semua rakyat termasuk dalam kalangan banduan penjara.
Penubuhan Makeshift Treatment Centre juga telah memberikan pengalaman baharu
kepada semua petugas barisan hadapan dan barisan pengurusan JKN Kedah
dalam menguruskan bencana di negeri Kedah dan berkongsi kepakaran dengan
agensi-agensi lain seperti ATM, NADMA dan pihak pengurusan KKM.

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TOCILIZUMAB FOR SEVERE COVID-19 PNEUMONIAS: CASE
SERIES OF 7 PATIENTS IN HOSPITAL SULTAN ABDUL HALIM

Peacchaima Purusothman1, Noralfazita Amran2, Aznita Ibrahim3

Department of Medicine Hospital Sultan Abdul Halim, Infectious Disease Unit
*Corresponding author: Peacchaima, Hospital Sultan Abdul Halim,[email protected]
_______________________________________________________________________________

ABSTRACT

Background: The objective of this case series is to describe the outcomes of
patients who received tocilizumab which reduce the length of stay in the hospital and
prevention of severe lung disease (organizing pneumonia) as well as reduces
mortality. Coronavirus (COVID-19) is associated with immune dysregulation and
hyperinflammation, including elevated interleukin-6 levels. The use of tocilizumab, a
monoclonal antibody against the interleukin-6 receptor, has resulted in better
outcomes in patients with severe Covid-19 in preventing major complications such
as severe organizing pneumonias and prolonged stay in hospitals.

Methodology: Case series

Results: We follow up on all patients who received tocilizumab from June 2021 to
December 2021. Less than 50% have died and were able to discharge from the
hospital. Four patients had survived out of seven patients. Two patients avoided
endotracheal intubations. The majority of the patients were able to cease oxygen
therapy. One significant adverse event potentially associated with tocilizumab
occurred in four patients was sepsis. Whereas two of our patients were confirmed
with pulmonary embolism. All patients received broad-spectrum antibiotics and
corticosteroids. The time from first tocilizumab administrations to improvement in
ventilation is defined as 50% improvements in PFRs ( po2/fio2 ratio) and reduction
of cytokine releasing syndrome(CRS) markers within 72 hours.

Conclusion:Usage of tocilizumab has reduced mortality and length of hospital
stays. It does not show directly causing pulmonary embolism. Usage of tocilizumab
potentially increases the risk of infections. Further studies with more patients are
required for better comparisons of the outcomes using Tocilizumab.

Keypoints: tocilizumab,organizing pneumonia,pulmonary embolism

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INTRODUCTION

Coronavirus disease (Covid-19) has rapidly developed into a global health threat since 2019.
The first case of covid-19 pneumonia was reported in Malaysia on 25th January 2020 which
was reported among travellers travelling from Singapore. Subsequently, Malaysia started to
face a significant rise in cases in the community. Till 5th January 2022 total 2,701,808 of
cases have been reported, with 257 cases requiring ICU admissions.

In Kedah, the total Covid-19 cases were 169,056 reported till 5th January 2022 with total
death of 2167 cases. Among the cases reported, 15 cases are currently requiring ICU
admissions and requiring ventilator support. Severe Covid-19 pneumonia is associated with
high mortality and admissions to intensive care units (ICUs) to provide mechanical
ventilation and other advanced forms of life support.

Glucocorticoids have been the mainstay of treatment in treating COVID-19 pneumonia,
however, prolonged usage of steroids has shown to increase the risk of severe infections,
especially in high-risk elderly groups. UK RECOVERY TRIAL usage of steroids
(dexamethasone 8mg OD for 10 days) showed 28 days of mortality improvement in 30% of
ventilated patients and 20% in oxygen requirement patients. Other options of treatment such
as JAK inhibitors such as baricitinib and available in Malaysia are limited in special groups
such as pregnancy affected with severe pneumonia with cytokine storm as well as chronic
kidney disease (CKD) patients.

Hence, the usage of tocilizumab was introduced based on serial case studies and research
trials. Tocilizumab is a humanized monoclonal antibody against the interleukin-6 receptor
(IL-6R) and is used to treat other inflammatory conditions such as rheumatoid arthritis as
well as cytokine releasing syndrome (CRS) after chimeric antigen receptor ( CAR)T cell
therapy in haematological malignancy patients. Covid-19 associated systemic
inflammations and hypoxemic respiratory failure can be associated with heightened cytokine
release as indicated by elevated Il-6, C-reactive proteins(CRP), D-dimers and ferritins. It is
hypothesized that modulating IL-6 levels or the effects of Il-6 may reduce the duration and/
or severity of Covid-19 pneumonia. Hence, the usage of tocilizumab has shown to have
better outcomes in patients with severe Covid-19 pneumonia.
This study was done to describe the outcomes and the complications observed from the
usage of tocilizumab in severe covid-19 pneumonia in Hospital Sultan Abdul Halim from
June 2021 to December 2021. The objective of this case series is to describe the outcomes
of patients who received tocilizumab which is the reduction of length of stay in hospital and
prevention of severe lung disease (organizing pneumonia) as well as reducing mortality and
studying the potential complications which were severe infections.

METHODOLOGY

We use case series to describe our patients. We included all the patients who received
tocilizumab for severe covid-19 types of pneumonia in Hospital Sultan Abdul Halim from

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June to December 2021. The decision to give tocilizumab was decided based on the severity
of the disease following the National Covid-19 guidelines which are:

 Within 14 days of illness
 with increased markers of Covid-19 associated systemic inflammation(CRP and

ferritin levels)
 clinical category 5
 non-invasive ventilation (NIV), including HFNC /mechanical ventilation
 severe sepsis was excluded before giving tocilizumab

The tocilizumab dose was 8mg/kg single dose (maximum dose: 800mg/dose) and given
intravenously. No IL-6 measurement was done because the reagent to do the test was run
out of stock. Severe sepsis in these cases before giving tocilizumab was ruled out by a chest
x-ray with no consolidations.

RESULTS

In our patients, it has been shown that the tocilizumab has reduced the stay in hospitals and
reduced the overall mortality. ( table 1, 2, 3). Our study also showed that there is a risk of
developing severe infection due to the usage of tocilizumab. (table 1,2,3). The risk of severe
organizing pneumonia was much reduced with the usage of tocilizumab. ( table 1,2,3).

Table 1 shows patient background, time‐course of admission and assessment before
tocilizumab (TCZ) administration shows. Patients from our data are majority males with a
mean age of 51-60 years old. Patients in our study had comorbid such as diabetes,
hypertension, obesity, and chronic kidney disease and two of our patients were pregnant
patients. Four of our patients were vaccinated at the time of presentations and three of our
patients were not vaccinated.

Table 2 shows the Tocilizumab treatment, other treatments received and response to
tocilizumab administration. The majority of the patients were given tocilizumab at mean day
8 of illness. The mean value of C-reactive proteins (CRP) and Ferritin levels in patients given
tocilizumab were 139 and 1021 respectively. The total white counts were ranging from 3000
to 13000 and consolidations suggestive of active infections from chest x-rays were excluded
before giving tocilizumab. All our patients in our study were given glucocorticoids mainly
methylprednisolone and dexamethasone. Five of our patients required mechanical
ventilation during their stay in ICU meanwhile two of our patients only required noninvasive
ventilation. The mean stay of our patients in the hospital after being given tocilizumab was
26 days.
Severe organizing pneumonias (OP)s were observed in two of our patients based on CT
findings, however, both patients were able to be discharged home without oxygen therapies.
Pre-eclampsia was seen in both pregnant patients, in which we couldn’t conclude the
tocilizumab directly caused the Pre-eclampsia, because of covid-19 pneumonia and the
pregnancy itself could cause the same complications. Pre-eclampsia was not seen among
the other two patients with CT findings. However, this data is limited as only four of our seven

376

patients has CT imaging done because of able to wean down oxygen very soon and some
of the patients were not stable to be done CTPA.

Only three mortality was observed in our patients with only one mortality involving vaccinated
patients. Severe sepsis with positive cultures was observed in our study as well, in which
three of our patients were treated for infection with culture proven. One of the patients was
also treated for septicaemic shock with multiorgan failure, unfortunately with no positive
culture. Table 3 shows clinical and laboratory parameters of COVID 19 patients before and
after TCZ treatment

Table 1: Patient background, time‐course of admission and assessment before

tocilizumab (TCZ) administration Patient 4 Patient 5 Patient 6 Patient
7
Patient 1 Patient 2 Patient 3 25 37 50 64
Female Female Male
Age 40 56 59 70kg Male
Gender Male Female Male 60kg 90kg 60kg
Weight 80kg 70kg 23 35 27
BMI 68kg (ht: 160) 22
29 26 24 (ht: 160) (ht: 160) (ht: 160)
Smoker (ht:165) (ht: 170) Non Non Non
(ht: 160) smoker Ex-
Ethnic Yes Non Non smoker smoker Malay smoker
Comorbidities smoker Malay Malay DM,HPT, Chinese
Indian smoker Chinese DM,HPT
Nil Chinese Pregnancy Pregnancy CKD
HPT 27 weeker 30 weeker, ,
Nil Obesity,T2 Sinovac IHD,CK
Astra (2 doses)
Vaccinations Nil Nil Nil Zeneca DM D
73 60 (2 doses) 112 Sinovac
Assessment 106 Pfizer
prior to TCZ: 106 (2 doses) (2
doses)
PF ratio 164
(PFR)mmHg 55

CRP 170 120 100 168 264 72 140

Ferritin 674 1980 2295 66 81 1512 1189
78 44 80 36 42 276 275
creatinine
8.0 9.9 3.5 15.2 12 8.4 13
Infection
screen: Absent Absent Absent Absent Absent Absent Absent

Total white
blood cell ( x
109/L)
CXR
consolidation

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Table 2: Tocilizumab treatment, other treatments received and r

TCZ dose Patient 1 Patient 2 Patient 3
Medication
480mg 560mg 480mg
Dose & Dose & Dose &
Duration Duration Duration
IVMTP 2mg/kg for MTP 2mg/kg for 2 MTP 2mg/kg for
5 days. days then for 5 days then
Tapered to IV Tapered to 1.5mg tapered to 1.5mg
Dexamethasone /kg for 2 days. /kg for 5 days,
12mg BD 2 days Subsequently then switch to IV
then 12mg OD 10 switch to IV Dexa 8mg bd for 2
days then switched Dexamethasone days then 8mg od
to oral 12 mg OD for 2 days then
prednisolone *Pulse IV MTP cont with oral
0.5mg/kg daily 500mg x 1 prior to prednisolone for
Toci. organising
pneumonia.

Events Days later Days later Days later
Timing from
days of TCZ to Nil Nil Not intubated
key clinical Nil Nil Day 21
events Nil Nil Day 40
Nil Nil Day 50
Extubation Death Death Alive

ICU discharge

O2 therapy
cessation

Hospital
discharge

Final day of
follow up

response to tocilizumab administration

Patient 4 Patient 5 Patient 6 Patient 7
400mg
400mg 400mg 560mg Dose &
Duration
Dose & Dose & Dose & MTP 2mg/kg for 2
days, then
Duration Duration Duration tapered to 1.5mg
/kg for 2 days 3
MTP 2mg/kg MTP 2mg/kg for 2 MTP 2mg/kg for 2 days then switch
to iv
Tapered to days then days then dexamethasone
12mg od for 2
1.5mg /kg for tapered to 1.5mg Tapered to 1.5mg days, then 8mg od
for 2 days then
for one day, /kg for 3 days then /kg for one day switch to iv
hydrocotisone
then switch to switch to IV dexa then switch to iv 50mg tds for 2
days
2 iv dexa 12mg 12mg od one day, dexamethasone
Days later
od 2 days, then then 8mg od for 3 12mg od for 2

8mg od 2 days, days, then 6mg od days, then 8mg od

then 6mg od for for 2 days and off for 2 days , then

2 days and off. 6mg od for 6 days

then switch to oral

prednisolone

0.5mg/kg for

organizing

pneumonia

treatment.

Days later Days later Days later

Day 3 Day 7 Not intubated Nil
Day 10 Day 9 Day 4 Nil
Day 11 Day 9 Day 6 Nil

Day 12 Day 21 Day 11 Nil

Alive Alive Alive Death

378

Table 2: Tocilizumab treatment, other treatments received and

Patient 1 Patient 2 Patient 3

Criterion Time vs TCZ Time vs TCZ Time vs TCZ
Response to
TCZ
administration

Defervescence Not Not Not
(fever < 38 related(baseline related(baseline related(baseline
degree C) afebrile) afebrile) afebrile)

Fio2 fall >25% Nil (increased Nil(increased Nil(increased
CRP fall > 25% requirement) requirement) requirement)
24h 24h 24h

CRP fall > 50% 72h 48h 48h

Ferritin fall > 1542(no change) 24h 24h
25%

Ferritin fall > 1254(no change) 72h Day 6
50%

Radiographic Worsening ARDS Improving ARDS Improving ARDS
improvement

Adverse events Bacteremia Sepsis with CRE Nil
(Klebsiella CRE VAP
bacteremia)

CT imaging Not done Not done OP

response to tocilizumab administration (continue)

Patient 4 Patient 5 Patient 6 Patient 7

Time vs TCZ Time vs TCZ Time vs TCZ Time vs TCZ

24 hr Not Not Not
related(baseline related(baseline related(baseline
Nil(increased afebrile) afebrile) afebrile)
requirement)
24h Nil(increased Nil(increased Nil(increased
requirement) requirement) requirement)
48h 24h 24h 48hr

Baseline not 48h 48h 72h
high
Baseline not high Less than 25% Increased trend
Baseline not
high Baseline not high Not done Increased trend

Improving Improving ARDS Improving ARDS Worsening ARDS
ARDS
Nil Nil Septicemic shock
Sepsis with with multiorgan
CRE VAP failure

PE PE OP Not done

379

Table 3: Clinical and laboratory parameters of COVID-19 patien

Before TCZ therapy

Case No. Day of Day of ICU Day of TCZ 1 2
hospitalization admission therapy

Ventilation and oxygenation

Patient 1 Time vs TCZ dose Same day Same day NIV NIV
O2 delivery FMO NIV NIV ETT
method 60(10L) 60 HFNC HFNC
Fio2(%) 106 130 ETT ETT
PF Ratio(mmHg) ETT ETT

Patient 2 Time vs TCZ dose 4d prior Day 4
O2 delivery TCZ admission
method HFMO 15L HFNC
Fio2(%) 95% 60%
PF Ratio(mmHg) 76 73

Patient 3 Time vs TCZ dose Same day Same day
O2 delivery HFMO 15L HFNC
method 95% 50%
Fio2(%) 60 100
PF Ratio(mmHg)

Patient 4 Time vs TCZ dose Day 5 Day 6
O2 delivery FMO 10L HFNC
method 60% 60%/60L
Fio2(%) 120 103
PF Ratio(mmHg)

Patient 5 Time vs TCZ dose Same day Same day
O2 delivery FMO 5L FMO10L
method 47% 60%
Fio2(%) 185 164
PF Ratio(mmHg)

nts before and after TCZ treatment Clinical
outcome
Days after TCZ therapy

3 4 5 6 7 8 9 10

ETT ETT ETT ETT ETT ETT ETT ETT Died at
Day 39 of
COVID
19

ETT ETT ETT ETT ETT ETT ETT ETT Died at
day 19 of
COVID
19

HFNC HFNC HFNC HFNC HFNC HFNC HFNC HFNC Alive ad
discharge
ward at
day 49 of
COVID

NIV NIV NIV HFNC HFNC HFNC NPO RA Alive and
discharge
at day 21
post
COVID

ETT ETT ETT ETT ETT FMO NPO RA Alive and
discharge
at day 20
post
COVID

380

Table 3: Clinical and laboratory parameters of COVID -19 patien

Case No. Before TCZ therapy

Day of Day of ICU Day of TCZ

hospitalization admission therapy 12

Patient 6 Time vs TCZ dose Day 2 Day 2 NIV HFN
O2 delivery HFMO 15L HFMO 15L
method 95% 95%
Fio2(%) 112.5 111.47
PF Ratio(mmHg)

Patient 7 Time vs TCZ dose Day 2 Day 2 ETT ETT
O2 delivery FMO 5L MCPAP
method 47% 100%
Fio2(%) 187 55.9
PF Ratio(mmHg)

nts before and after TCZ treatment (continue) Clinical
outcome
Days after TCZ therapy

3 4 5 6 7 8 9 10

NC HFNC VMO NPO NPO RA RA RA RA Alive and
discharge
at day 21
post
COVID

ETT ETT ETT ETT ETT ETT ETT ETT Died at
day 15 of
COVID
19

381

Figures 1, 2 and 3 show CRP, Ferritin, and PFR trends before and after 72 hours of
Tocilizumab. From our data, it is observed that the cytokine releasing storm ( CRS)
parameters which were observed using CRPs and ferritins, showed >50% reductions post
tocilizumab in 72hours. The PFR (po2/fio2) ratio was also noted to have improvement post
tocilizumab 72hours.

Figure 1: CRP Trend before and after 72 hours Tocilizumab

Figure 2: Ferritin Trend before and after 72 hours Tocilizumab

Figure 3: PFR before and after 72 hours Tocilizumab

382

Case summary
Patient 1
40 years old gentleman with no known medical illness, presented with covid-19 pneumonia
under room air on day 6 during presentations and rapidly deteriorated on day 8 of illness
requiring non-invasive mechanical ventilation and tocilizumab 480mg was given ( BW:
80kg). He was then intubated for worsening respiratory distress during the day. His CRS (
cytokine releasing syndrome) improved after 72 hours of tocilizumab however, subsequently
patient succumbed to ventilator-associated pneumonia with a positive culture of CRE
klebsiella.

Patient 2
56 years old gentleman with no known medical illness presented with covid-19 pneumonia
on day 5 of illness and required npo2 oxygenation during presentations. He rapidly
deteriorated on day 9 of illness requiring non-invasive mechanical ventilation and
tocilizumab 480mg was given. He continued to deteriorate on day 11 of illness and required
intubations. He was treated for ventilator-associated pneumonia as noted his tracheal
culture was Klebsiella CRE, however, he still succumbed to his illness.

Patient 3
59 years old with no known medical illness, presented with covid 19 pneumonia at day 8 of
illness requiring high flow mask oxygenation during presentations and rapidly deteriorated
at day 9 of illness requiring non-invasive ventilation and tocilizumab 480mg stat was given.
His CRS parameters and oxygenations continued to improve 72 hours post tocilizumab. He
required a long stay in the ward for pulmonary rehabilitation in which CT scan findings
confirmed organising pneumonia. However, he was discharged home well without oxygen
supplement on day 49 of illness. He was followed up at the chest clinic with repeat HRCT
thorax which showed improving organising pneumonia and he was discharged from the
chest clinic.

Patient 4
25 years old, with no known medical illness, G3P1 + 1 @ 23weeks pregnancy initially
presented at day 4 of illness under room air. On day 5 of illness, noted the patient was
having persistent fever with tachycardia with raised CRP and CXR noted bilateral ground-
glass opacity without desaturations, hence, IV dexamethasone 8mg OD was initiated.

However on day 8 of illness, noted she desaturated and required face mask oxygenations
with increasing CRP( 78 ----172), hence IV methylprednisolone was started. She continued
to deteriorate and required High flow nasal cannula hence tocilizumab 400mg was initiated
on day 9 of the illness. Before starting tocilizumab, CTPA was done to exclude consolidating
pneumonia, in which CTPA resulted in pulmonary embolism. She was intubated on day 10
of illness (24h after Tocilizumab), however, her clinical parameters and oxygenation
improved within 48-72 hours post tocilizumab and she was successfully extubated on day
12.

383

However, after extubating, noted her septic parameters were increasing in trend. Her total
white counts remained elevated with the spiking of fevers (17000 to 25000). Her culture was
positive for CRE klebsiella from the tracheal aspirate. She was treated with polymyxin B for
6 days and the patient was subsequently discharged on day 21 of illness under room air as
the patient requested discharge at her own risk. She was reviewed in the post-Covid-19
clinic and she remained well with her saturation remaining 98% under room air.

Patient 5
37 years old, G3P1 +1 @ 29 weeks with underlying type 2 diabetes and maternal obesity
with BMI 32, presented at day 7 of illness requiring face mask oxygenations. Upon
presentations to the emergency department, she was referred to ICU care for close
observations. Her CRS parameters upon presentations were CRP, 260 with PFR was 164,
hence tocilizumab 400mg stat was started with iv methylprednisolone. She continued to
deteriorate on day 10 of illness (post-Tocilizumab day 3) requiring mechanical ventilation
with a high setting (bilevel fio2:1). CTPA was done and noted severe lung involvement with
pulmonary embolism.

She was subjected to an emergency lower caesarean section on day 12 of illness and the
baby was nursed in NICU post-delivery. She continued to improve and was extubated well
on day 14 of illness. She contracted CRE klebsiella from her rectal swab screening, which
was not treated clinically she did deteriorate but further improved well. She was discharged
well on day 20 of illness. Post-discharge, she was reviewed at a post-natal clinic where she
remained well.

Patient 6
50 years old, with underlying type 2 diabetes mellitus and chronic kidney disease presented
with severe covid 19 pneumonia at day 7 of illness requiring high flow mask oxygenation at
presentations. He continued to deteriorate on day 9 of his illness requiring non-invasive
mechanical ventilation. Hence, IV tocilizumab 560mg stat was decided to give with iv
methylprednisolone. He continued to improve within 72 hours of post tocilizumab, and his
oxygenation was able to taper down to face mask oxygenations. During the stay, CTPA was
done and noted organizing pneumonia with no pulmonary embolism. He was discharged
well on day 21 of illness with a tapering dose of prednisolone and was given a chest clinic
follow up with HRCT appointment.

Patient 7
64 years old, with underlying hypertension, diabetes, ischaemic heart disease and chronic
kidney disease presented with severe covid-19 pneumonia at day 5 of illness requiring face
mask oxygenations. On day 7 of illness, he continued to deteriorate and required
mechanical intubations and IV tocilizumab 400mg stat was given. He continued to
deteriorate with anuria and worsening kidney failure and required haemodialysis support on
day 9 of illness. He was started on a broad spectrum of antibiotics, however, he remained
ill and succumbed to illness on day 15 of illness.

384

DISCUSSIONS

We present the first Kedah state cases of tocilizumab use in Covid-19, comprising seven
patients with severe Covid-19 pneumonia and clinical suspicion for CRS. Our retrospective,
case series should be interpreted with caution. Nevertheless, we believe it is vital that such
cases are published to inform current experience and to generate clinical hypotheses about
the mechanisms of disease and the potential for interventions.

The recommended dose of tocilizumab dose is 8mg/kg single dose ( maximum dose:
800mg/dose), however some of our patients received a variation dose of Tocilizumab due
to earlier recommendations being based on weight, however, the current guide advised
using fixed-dose based on weight whereby less than 80kg start with 400mg and more than
80kg may use 560mg stat dose. This is because of the limited stock available for this drug.

Our study showed that the mean day of illness given tocilizumab were 8 days with criteria
of severe Covid-19 pneumonias in which the mean value of C-reactive proteins (CRP) and
Ferritin levels in patients given tocilizumab were 139 and 1021 respectively. As we expect
the CRS storm mainly occurred after Day 7 of COVID 19 illness with significant-high CRP
and Ferritin levels. Of central importance is whether the inflammatory response to COVID
19 is an adaptive, response to severe infection, and when, if at all, pathogenic hyper
inflammation occurs. Raised levels of IL-6 have been shown to predict poor outcomes in
severe COVID 19 infection, and our data add to the published literature suggesting IL-6
pathway inhibition may be beneficial( Harold et all, 2020). However, IL-6 levels are also
elevated in sepsis ( Kruttgen et al, 2012) where immune interventions have failed to show
benefits. (Peters et all, 2018) Further research into the immune response to COVID 19
infections is required.

The majority of our patients were vaccinated and three of our patients who were given
tocilizumab earlier were not vaccinated as our national vaccination program was targeting
communities with comorbid and ages more than 60 as well as front liners during the earlier
phase of vaccination programs.
All our patients were receiving invasive and noninvasive mechanical ventilation. Four of our
patients who were given tocilizumab were discharged well without requiring long term
oxygen therapy. In papers published by the New Journal of England (Ivan et all), regarding
the usage of tocilizumab for severe covid-19 pneumonia, it has been shown that in patients
with covid-19 pneumonia who were not receiving mechanical ventilation, tocilizumab
reduced the likelihood of progression to the composite outcome of mechanical ventilation or
death, but it did not improve survival rate. The same paper also observed the primary
outcome was mechanical ventilation or death by day 28 which was also seen in three
mortalities. However, in our study, mean hospital stays were 26 days in those discharged
home well.
The risk of infections which was observed in our patients with all patients’ positive cultures
was high. Three of our patients were treated for severe sepsis with who cases positive
cultures for carbapenem-resistant Enterobacteriaceae. However, one case complicated with

385

septicaemic shock with multiorgan failure showed persistent high total white blood cells and
worsening thrombocytopenia but no positive culture and post succumbed subsequently.

In a paper published by PubMed the rationale use of Tocilizumab in the treatment of covid-
19 pneumonia (Shengyu, 2020), has discussed the usage of tocilizumab in special groups
especially the elderly>65 years old and pregnancy. The paper discussed that patients
aged ≥ 65 years treated with tocilizumab have a higher rate of severe infection than
patients ≤ 65 years. Our data showed that the risk of infection was high regardless of the
age group. The same paper also discussed that tocilizumab actively crosses the placenta in
late pregnancy and may affect the fetal immune response. However, according to our data,
two of our patients were pregnant at 27-30 weeks and one of them delivered prematurely
with the baby needing incubators meanwhile whereas another pregnant patient was
discharged well without any complications to the current pregnancy.

Of four of our patients with CT imaging, three of them showed OP changes. However, all of
them recovered well without requiring long term oxygen therapy and the majority of them
were discharged well within 28 days. In PubMed ( Shengyu,2020) the rationale of
tocilizumab usage was discussed that the respiratory function and oxygenation index was
improved with CT scan showed obvious improvement of pulmonary lesions in their patients.
Therefore, the paper concluded that for patients with severe COVID-19 caused by cytokine
storm, tocilizumab is a drug worthy of clinical research. In our study, the majority of our
patients showed improvements in CRS parameters within 72 hours served tocilizumab, with
also improvement in PFRs. This is also supported by the REMCAP trial in April 2021 among
critically ill patients with COVID 19 receiving organ support in ICUs, treatment with
Interleukin-6 receptor antagonists Tocilizumab and Sarilumab improved outcomes,
including survival.

The major limitations of our study were the number of patients. Our data are limited to only
seven patients at the time of study for these case series as only seven patients were given
tocilizumab because of limited drug availability in our hospital. The dose and schedule of
tocilizumab used in our series varied between patients, and there is treatment heterogeneity
in the published literature ( Coomes 2020). If global supply comes under strain, the needs
of both COVID-19 and non-COVID-19 patients for tocilizumab will need to be considered.

CONCLUSION

In conclusion, tocilizumab did reduce the length of stay in hospital and reduce mortality in
patients with severe Covid-19 pneumonia as well as reducing long term lung damage with
marked reductions of CRS parameters. It may potentially increase the risk of infections in
these groups of patients regardless of age. The series illustrates that tocilizumab can be
associated with favourable clinical outcomes in some cases of severe covid-19 pneumonia.

386

RECOMMENDATIONS

The National Covid-19 guidelines 2021 recommends that Il-6 blockade be considered early
in critically ill patients with severe covid 19 pneumonia. We conclude with these
recommendations and advocate for collaborative, multidisciplinary management of such
patients, including judicious use of tocilizumab as limited stock is available.

ACKNOWLEDGEMENT

The authors would like to thank the Director General of Health Malaysia for his permission
to publish this article I would like to thank our head of department of medicine, Dr Aznita
Ibrahim for all the supports in helping in the management of covid patients in Hospital Sultan
Abdul Halim. I also would like to thank our infectious disease physician, Dr Noralfazita Amran
for all the guidance and teachings to complete this study. Also would like to thank our Clinical
Research Centre(CRC) pharmacist, Miss Tiew.

REFERENCES

CORON-ACT, a Multicenter, Double-blind, Randomized Controlled Phase II Trial on the
Efficacy and Safety of Tocilizumab in the Treatment of Coronavirus Induced Disease
(COVID-19), 2020

Coomes EA, Haghbayan H. Interleukin-6 in COVID- 19: a systematic review and meta-
analysis. medRxiv preprint server. 2022020.03.30.20048058, 2020

Herold T, Jurinovic V, Arnreich C, et al. Level of IL-6 predicts respiratory failure in
hospitalized symptomatic COVID-19 patients. medRxiv 2020

Ivan O. Rosas, M.D.et all, Tocilizumab in Hospitalized Patients with Severe Covid-19
Pneumonia, The New England Journal of Medicine, April 2021

Kruttgen A, Rose-John S. Interleukin-6 in sepsis and capillary leak- age syndrome. J
Interferon Cytokine Res. 2012

Peters van Ton AM, Kox M, Abdo WF, Pickkers P. Precision immunotherapy for sepsis.
Front Immunol. 2018

Shengyu et all, Rationale Use of Tocilizumab in the Treatment of Novel Coronavirus
Pneumonia, PubMed, 2020

Clinical practise guidelines on covid 19 management, 2021
National covid 19 immunization programs, Wikipedia,2021
http://ww.ncbi.nlm.nih.gov/pmc/articles/PMC74366

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PENGUATKUASAAN AKTA 342 DALAM KAWALAN PANDEMIK
COVID-19 DI KEDAH

Unit Inspektorat dan Perundangan, Jabatan Kesihatan Negeri Kedah

PENGENALAN

Pandemik Covid-19 mula melanda negara kita sejak Januari 2020 apabila terdapat
3 warga China memasuki Malaysia melalui Singapura. Sejak dari itu, bermulalah
episod kes-kes baharu yang mana turut melibatkan warganegara Malaysia. Di
negeri Kedah, kes pertama juga dicatatkan pada bulan Januari 2020 di mana
melibatkan seorang pelancong dari China yang memasuki Langkawi. Bagi kes
tempatan, Kuala Muda merupakan daerah pertama yang dikesan terdapatnya kes
Covid-19. Susulan dari kes-kes Covid-19 ini, negara kita dikejutkan pula dengan
kluster Covid-19 dan di antara kluster yang besar dan menjadi perbualan ramai
adalah kluster Sri Petaling (Selangor) dan kluster Sivagangga (Kedah).

Sepertimana yang kita sedia maklum, hos atau perumah virus berbahaya ini adalah
manusia. Oleh yang demikian, kawalan pergerakan manusia merupakan langkah
utama dalam menentukan perebakan kes. Akta Pencegahan dan Pengawalan
Penyakit Berjangkit 1988 atau lebih dikenali sebagai Akta 342 merupakan senjata
utama yang digunakan oleh kerajaan dalam menangani pandemik Covid-19.

PENGUATKUASAAN AKTA 342

Akta 342 telah lama dikuatkuasakan oleh Kementerian Kesihatan Malaysia (KKM)
khasnya di Pejabat Kesihatan Dearah (PKD). Penguatkuasaan Akta 342 pada
asasnya adalah dipertanggungjawabkan kepada Pegawai dan Penolong Pegawai
Kesihatan Persekitaran (PKP/PPKP) iaitu dahulunya dikenali sebagai Inspektor
Kesihatan di mana telah dilantik sebagai pegawai diberikuasa di bawah Seksyen 3
akta yang sama. Akta ini digunakan di PKD bagi tujuan mengawal dan mencegah
penyakit berjangkit yang lain. Pada peringkat awal pandemik Covid-19 melanda
negara, beberapa seksyen penting telah digunakan dalam penguatkuasaan ini di
antaranya adalah seksyen 10 berkaitan keperluan notifikasi penyakit berjangkit;
seksyen 11 berkaitan pengistiharan kawasan tempat jangkitan dan rawatan serta
pengasingan pesakit dan seksyen 18 iaitu berkaitan penutupan premis bagi tujuan
membasmi kuman. Melihat kepada kepentingan penguatkuasaan Akta 342,
perluasan penggunaan seksyen yang terdapat di dalam akta digunakan
sepenuhnya.

388

Fasa Kawalan Covid-19
Pandemik Covid-19 yang tidak terkawal dan juga belum ada ubat yang mampu
mengubati penyakit ini, maka kawalan secara keseluruhan telah diambil alih oleh
Majlis Keselamatan Negara (MKN). Dengan pengambil alihan oleh MKN, maka SOP
dikeluarkan bagi tujuan mengawal dari segi pegerakan manusia dan amalan norma
baharu bagi membendung penularan kes. Pelbagai siri SOP dikeluarkan dengan
pindaan dari masa ke semasa bergantung kepada situasi dan tempat berlakunya
kes seperti :-

i. SOP Perintah Kawalan Pergerakan (PKP)
ii. SOP Perintah Kawalan Pergerakan Bersyarat (PKPB)
iii. SOP Perintah Kawalan Pergerakan Diperketat (PKPD)
iv. SOP Perintah Kawalan Pergerakan Pemulihan (PKPP)
v. Pelan Pemulihan Negara Fasa 1
vi. Pelan Pemulihan Negara Fasa 2
vii. Pelan Pemulihan Negara Fasa 3
viii. Pelan Pemulihan Negara Fasa 4

Dengan bebanan dalam pengawalan dan siasatan kes Covid-19 yang semakin
meningkat telah menyebabkan mobilisasi anggota melibatkan PKP/PPKP di mana
PPKP dari unit-unit yang lain dari PKD telah dipanggil untuk membantu PPKP di Unit
Kawalan Penyakit Berjangkit untuk menjalankan aktiviti-aktiviti yang berkaitan
seperti penyiasatan kes, penutupan premis, pengeluaran Perintah Kuarantin Di
Rumah (HSO), sucihama premis, pengurusan mayat dan lain-lain aktiviti yang
berkaitan. Mobilisasi juga turut berlaku di antara daerah dengan daerah. Ini adalah
kerana peningkatan kes yang mendadak di beberapa daerah seperti Kubang Pasu,
Kota Setar, Kuala Muda dan Kulim. Aktiviti penguatkuasaan pematuhan SOP oleh
PPKP amat terbatas atas faktor tugas kawalan dan siasatan kes. Oleh yang
demikian, YAB Menteri Kesihatan telah melantik beberapa agensi bagi membantu
menguatkuasakan Akta 342 iaitu seperti Polis, Imgresen, Kastam, Penguatkuasa di
Pihak Berkuasa Tempatan, KPDNHEP dan lain-lain agensi. Dalam masa yang
sama, anggota sedia ada di bawah KKM seperti Pegawai Perubatan, Jururawat,
Pembantu Perubatan dan Pembantu Kesihatan Awam turut dilantik sebagai
pegawai diberikuasa bagi membantu melaksanakan aktiviti HSO.

Penguatkuasaan Kawalan Pergerakan
Penguatkuasaan kawalan pergerakan terbahagi kepada dua iaitu pergerakan
merentas daerah/negeri serta HSO. Larangan pergerakan merentas sempadan
daerah/negeri dilaksanakan melalui sekatan jalanraya yang diketuai oleh PDRM dan
dibantu oleh anggota Tentera, Pertahanan Awam dan RELA. Dengan larangan ini,

389