Laporan Teknikal Jabatan Kesihatan Negeri Kedah 2022

PENGENALAN

Isu mengenai COVID-19 menjadi berita hangat di seluruh dunia menjelang hujung
tahun 2019. Ini menandakan isu kesihatan ini merupakan isu global, bukan isu
Malaysia sahaja. Sejak wabak penyakit virus Corona 2019 (COVID-19) di bandar
Wuhan, China sehingga kemunculan kes pertama COVID-19 di Malaysia pada 25
Januari 2020 (Harits, 2020). Rentetan langkah pencegahan penularan jangkitan,
Pertubuhan Kesihatan Sedunia telah memperkenalkan norma baharu, termasuk
langkah pengasingan untuk kes positif, pengesanan kontak rapat dan arahan
kuarantin, kerap cuci tangan, memakai pelitup muka di tempat awam serta menjaga
jarak fizikal dengan orang lain. Yang menjadi persoalan, berapa lama masyarakat
daripada pelbagai kategori terpaksa hidup dalam keadaan yang tidak menentu, tidak
selesa dan tidak selamat daripada situasi pandemik. Menjawab kepada situasi yang
berlaku kehidupan norma baharu menjadi strategi alternatif untuk keluar daripada
pandemik ini.

Mengukur kesiapsiagaan masyarakat dalam menghadapi era norma baru,
sekurang-kurangnya dapat dilihat dari sudut kekuatan masyarakat yang saling
mendukung sehingga masyarakat benar-benar membuktikan mereka sebagai
tonggak kemajuan pembangunan nasional dalam semua keadaan. Pengukuran
hasil mungkin tidak mengambil kira proses yang terlibat dalam pemerkasaan
komuniti, seperti pembinaan kapasiti dan membangunkan kecekapan, kemahiran
dan kesedaran kritikal (Kieffer, 1984).

Tindakan pemerkasaan komuniti merupakan satu usaha untuk memberikan kuasa
atau kekuatan kepada masyarakat untuk keluar daripada masalah yang
dihadapinya. Ia juga bertujuan untuk menjadikan manusia berdikari supaya mereka
dapat menghadapi pelbagai cabaran dalam kehidupan mereka. (Mustangin et al.,
2017).

Tinjauan Amalan Norma Baharu yang dijalankan oleh Institut Penyelidikan
Tingkahlaku Kesihatan pada bulan April - Julai 2020, Universiti Teknologi Mara pada
Ogos 2020, Bahagian Pendidikan Kesihatan pada November 2020 dan Institut
Penyelidikan Tingkahlaku Kesihatan semula pada Mei 2021 menunjukkan trend
pematuhan amalan norma baharu melalui tiga komponen amalan cuci tangan,
penjarakan sosial dan pemakaian pelitup muka kian menurun sehingga Mei 2021.
Bermula dengan 98.9% untuk kerap cuci tangan, 98.8% menjaga jarak sosial dan
98.3% untuk pemakaian pelitup muka pada awal norma baharu dipekenalkan
namun menurun hingga 85% untuk amalan cuci tangan, 87.7% untuk penjarakan
fizikal dan 95.6% untuk pemakaian pelitup muka.

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Tinjauan penerimaan dan penolakan vaksin covid 19 yang dilaksanakan oleh
Universiti Malaya pada 3-12 April 2020 sebanyak 94.3% responden bersetuju untuk
menerima vaksin. Tinjauan oleh Institute Clinical Research pada 10 Julai hingga 31
Ogos 2020 pula sebanyak 93.2% responden yang bersetuju untuk menerima vaksin
manakala 4.7% menyatakan tidak pasti untuk menerimanya dan selebihnya
menolak. Tinjauan oleh Bahagian Pendidikan Kesihatan pada 21-28 Disember 2020
pula 67.0% bersetuju untuk menerima vaksin manakala 17.0% menyatakan tidak
pasti selebihnya menolak. Manakala tinjuauan oleh Univesiti Sains Islam Malaysia
pada Januari 2021 menunjukkan 78% responden yang bersetuju untuk menerima
vaksin dan tinjauan sekali lagi dibuat oleh Bahagian Pendidikan Kesihatan pada 3
hingga 16 April 2021 85% responden mengatakan setuju untuk menerima vaksin
manakala 10% mengatakan tidak pasti dan selebihnya menolak.

Rentetan daripada situasi semasa yang berlaku, Unit Promosi Kesihatan perlu
memainkan peranan untuk memperkasa komuniti melalui melalui pendidikan dan
promosi agar dapat meningkatkan pengetahuan dan kesedaran komuniti terhadap
pandemik, meningkatkan keupayaan komuniti untuk bertindak terhadap sebarang
kejadian pandemik, meningkatkan kesiapsiagaan komuniti terhadap sebarang
kejadian pandemik, melaksanakan inisiatif pemantauan terhadap pematuhan
Standarad Operating Prosedur (SOP) dan norma baharu melalui hebahan berkaitan
pendidikan kesihatan serta membantu promosi untuk meningkatkan pendaftaran
penerima vaksin dalam program Imunisasi COVID-19 Kebangsaan dan
memperkasa komuniti dalam perubahan tingkahlaku kesihatan dalam pencegahan
penyakit berjangkit/tidak berjangkit dan menggalakkan amalan cara hidup sihat.

Sepanjang tahun 2021, aktiviti Unit Promosi Kesihatan dalam proses
memperkasakan komuniti melalui District Risk Reduction Program ( DRRP)
tanggungjawab komuniti untuk mengekalkan daerah hijau dan boleh dicapai melalui
kepatuhan individu, keluarga dan komuniti kepada amalan CAPP, Cegah, & Didik,
Amal, Patuh dan pantau. Antara aktiviti yang dilaksanakan menggunakan kaedah
komunikasi massa seperti hebahan awam yang menggunakan Unit Bergerak.

Advokasi - Didalam suasana pandemik COVID19 yang melanda, dengan kekuatan
sebuah kereta, unit ini tidak mampu untuk membuat liputan menyeluruh di daerah
Kuala Muda, lalu unit mengambil keputusan untuk membuat hebahan dengan
berkolaborasi bersama inter agensi yang melibatkan, Jabatan Penerangan, Pejabat
Daerah Kuala Muda, Majlis Perbandaran Sungai Petani Kedah bermula 20 Mei
2021, Unit Bergerak Jabatan Kesihatan Negeri Kedah pada 6 Jun 2021 dan bantuan
polis komuniti bermula 15 Jun 2021 dengan strategi lebih bertumpu kepada
pembahagian mukim mengikut agensi agar lebih berfokus. Ini juga dikategorikan

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pemerkasaaan komuniti dimana pelbagai agensi sedia berkerjasama untuk
membantu dalam hebahan sewaktu krisis ini.

Komunikasi hubungan awam - menjadi kebiasaan sebelum ini skrip hebahan
menggunakan ayat-ayat Melayu baku sahaja. Namun sewaktu pandemik ini berlaku
terlalu banyak maklumat yang tidak betul sama ada melalui tulisan di media sosial
atau voice note yang memberikan maklumat yang salah untuk tujuan menakutkan
masyarakat dengan menggunakan loghat tempatan dan dia mendapat tempat di hati
masyarakat. Tidak terkecuali berlaku di Kuala Muda. Sementelahan itu, unit ini telah
mengubah strategi dengan membacakan skrip hebahan menggunakan loghat
tempatan dengan bahasa yang lebih mudah dan ringkas. Video kenderaan bergerak
ini teah dirakam oleh orang awam dan menjadi tular di pelbagai platform sosial
media bermula 15 Jun 2021 antaranya melalui WhatsApp, Enggagement Facebook
(FB) KEDAHLANIE mempunyai 1.3 juta views, Tiktok Era FM ( Malaysia) 560 like,
103 shares 57k views Instagram era.je 305,455 views.

Media Sosial - Unit Promosi Kesihatan Jabatan Kesihatan Negeri Kedah telah
menerbitkan video animasi menggunakan watak Cik Ju menggunakan loghat yang
sama dan telah dimuatnaik di Facebook Pejabat Kesihatan Daerah Kuala Muda
Rasmi pada 22 Jun 2021 dengan 24 ribu tontonan. Unit ini juga sentiasa
mengemaskini Facebook Pejabat Kesihatan Daerah Kuala Muda setiap hari,
memuat naik informasi mengenai COVID19, isu semasa dan vaksinasi, hebahan
sistem temujanji klinik dan lain-lain kerana di didalam suasana pandemik ini, sosial
media adalah medium paling ampuh, tiada melibatkan kos dan paling tepat untuk
menyampaikan maklumat kepada penduduk. Laporan Digital pada 2018 yang
dikeluarkan oleh HootSuit dan We are Social menyatakan jumlah pengguna Internet
dinegara ini menunjukkan peningkatan kepada 25.08 juta pengguna, mewakili 79
peratus penduduk Malaysia.

Media Konvensional - Memasang gegantung sebagai signal komunikasi kepada
penduduk setempat bahawa kawasan mereka merupakan kawasan merah covid19,
unit ini juga memasang gegantung berbentuk tiga segi untuk memberikan petunjuk
kepada penduduk kawasan sekitar supaya mereka cakna dengan situasi semasa
di Kuala Muda. Pemasangan gegantung ini telah diambil gambar oleh penduduk dan
tular melalui group Whatsapp komuniti setempat dan di beberapa page Facebook
komuniti Sungai Petani dan Kedah.

Rumours Surveillance – daripada jumlah berkenaan 75 peratus menggunakan
perkhidmatan media sosial dan memperuntukkan purata tiga jam sehari di laman
media sosial. (Hadri, 2018). Disamping memuat naik informasi, unit ini juga

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melakukan rumors surveillance dengan setiap hari memantau dan memberi respon
kepada komen-komen di FB yang dirasakan perlu diberi perhatian dan tindakan
segera. Ini adalah salah satu strategi komunikasi risiko untuk memberi maklumat
yang tepat kepada pemegang taruh tentang sesuatu isu. Hasil daripada respon
pengikut, dapat dibuktikan masyarakat sudah ada pemerkasaan komuniti yang
mana mereka sering melaporkan jika ada berlaku ketidak patuhan SOP ditempat
kerja atau komuniti mereka.

Terbitan Media -Unit ini juga menerbitkan beberapa video berdurasi 30 saat yang
memfokuskan mengenai amalan norma baharu untuk memberi gambaran dan
suasana mengadaptasi norma baharu yang dimuat naik ke Facebook. Untuk
memperkukuhkan pemahaman unit ini juga menerbitkan tujuh infografik berkenaan
tanggungjawab semua pihak dalam menurunkan kes Covid 19 yang juga dipaparkan
ke FB.

Jerayawara – Jerayawara pendaftaran vaksin di lapan kawasan tumpuan awam dan
institusi pengajian tinggi. Selain itu, unit ini juga dibantu oleh pasukan COMBI
(Communication for Behavioral Impact) juga melakukan promosi pendaftaran vaksin
di komuniti masing-masing.

HASIL KAJIAN
Liputan vaksinasi - Hasilnya dapat kita lihat di Kuala Muda peratusan liputan
vaksinasi COVID-19 untuk populasi 18 tahun ke atas adalah 89%,telah disuntik,
10.3% tidak vaksin dan 0.7% tidak mendapatkan vaksinasi sehingga 12 Januari
2022. Manakala prestasi suntikan vaksin COVID-19 untuk populasi remaja 12-17
tahun adalah membanggakan iaitu 100.2% dan 4.8% yang vaksinasi tidak lengkap
2 dos. Manakala sejak dilancarkan kaedah datang terus ke Pusat Pemberian vaksin
tanpa temujanji, dapatan sepanjang 28 Ogos sehingga 14 September 2021, seramai
6722 orang telah datang mendapatkan vaksin COVID 19 mereka.
Kehadiran datang terus ke CAC - Meskipun di dalam komen page Facebook
mendapat pelbagai kecaman, yang nyata kehadiran secara datang terus ke COVID
Asessment Centre (CAC) adalah memberansangkan setelah masyarakat membuat
ujian Rapit Test Kit (RTK) Antigen (AG) sendiri di klinik apabila terdapat simptom
COVID19. Ini sekali lagi membuktikan tingkahlaku cepat mendapatkan rawatan
semakin baik. Dapatan yang didapati bermula Ogos sehingga Disember 2021
mendapati seramai 29632 pesakit telah datang ke CAC dan 109 ( 0.37%)
daripadanya adalah datang terus setelah mendapat tahu keputusan ujian saringan
COVID19 mereka adalah positif setelah hebahan yang dibuat melalui face book
bahawa mereka yang telah positif RTK AG yang dilakukan oleh pengamal perubatan
atau positif RTK AG manakala Saringan Kendiri (air liur dan calitan hidung) boleh
datang terus ke CAC tanpa perlu menunggu dihubungi oleh pejabat ini.

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Kehadiran datang terus kontak rapat ke khemah saringan - Unit ini juga ada
menghebahkan supaya kontak rapat yang belum dihubungi oleh pejabat kesihatan
untuk datang terus ke khemah saringan tanpa menunggu panggilan daripada
pejabat kesihatan untuk membuat saringan. Dapatan yang dikumpul bermula
September sehingga Disember 2021 seramai 19793 klien telah datang ke khemah
Saringan COVID 19, 9829 (49.6%) daripadanya adalah datang sendiri dan mengaku
sebagai kontak rapat tanpa menunggu panggilan daripada pejabat ini untuk diarah
menjalankan saringan. Ini sekaligus membuktikan komuniti juga telah diperkasakan
dan merasakan mereka perlu menjalani saringan untuk mengetahui status diri
mereka samaada positif atau tidak setelah mereka mengetahui mereka kontak
rapat.

Pematuhan SOP - Semenjak berlaku pandemik ini operasi pematuhan SOP di kedai-
kedai, kilang-kilang dan institusi juga dilakukan oleh Unit Inspektorat dan
Perundangan. Sepanjang tahun 2021 sebanyak 241 premis telah dikunjungi dan
170 premis (70.54%) telah didapati mematuhi SOP. Ini sekali lagi membuktikan
premis-premis di sekitar Kuala Muda ini mampu untuk mempersiapkan premis
mereka untuk memenuhi keperluan mengikuti SOP seperti pemakaian pelitup muka,
jaga jarak fizikal 1 meter dan kurang aduan mengenai ketidakpatuhan dalam
mendepani COVID 19 ini.

Hebahan Sistem Temujanji Klinik - Sepanjang pandemik ini juga klinik kesihatan di
seluruh Malaysia telah mengamalkan sesi temujanji atas talian sepenuhnya untuk
kedatangan ke klinik untuk semua perkhidmatan termasuk rawatan pesakit luar,
saringan kesihatan dan saringan pra perkahwinan, tidak terkecuali di daerah Kuala
Muda. Hasil temubual bersama 8 ketua klinik memberi respon yang positif terhadap
kepatuhan klien dalam kedatangan ke klinik mengikut temujanji dan ini sekaligus
mengelakkan kesesakkan. Ini sekali lagi membuktikan bahawa komuniti juga
bersedia untuk mematuhi norma baharu yang perlu dipatuhi bagi menjaga jarak
fizikal sekuran-kurangnya 1 meter untuk mengurangkan risiko jangkitan.

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Suasana di Klinik Kesihatan Bandar Sungai Petani pada Ahad 16 Januari 2022.

RUMUSAN
Pemerkasaan komuniti ini bukanlah sesuatu yang mudah tetapi bukan sesuatu yang
mustahil untuk dicapai kerana setiap sesuatu itu bermula daripada kita iaitu setiap
individu yang mewakili komuniti tersebut. Dalam tempoh pandemik COVID19
sekarang, komuniti yang diperkasakan akan berusaha secara kolektif untuk
menghalang jangkitan COVID19 ke dalam komuniti. Tidak dinafikan bahawa
pemerkasaan komuniti akan mengambil masa kerana dalam proses tersebut,
banyak faktor yang menjadi kebiasaan dalam komuniti perlu diubah. Jalan singkat
boleh diambil dan ianya lebih mudah cepat dan murah. Namun pemerkasaan
komuniti akan mengambil masa kerana ianya melibatkan komuniti untuk
diperkasakan.

PENGHARGAAN
Penulis ingin mengucapkan setinggi-tinggi penghargaan kepada Ketua Pengarah
Kesihatan kerana kebenaran untuk menerbitkan artikel ini Apresiasi ini ditujukan
kepada PICK Daerah Kuala Muda, Bilik Gerakan COVID19 Kuala Muda, Khemah
Saringan COVID19 Kuala Muda, Unit Inspektorat dan Perundangan Kuala Muda,
Unit Promosi Kesihatan Jabatan Kesihatan Negeri Kedah kerana sudi memberikan
data-data harian untuk dijadikan hasil tidak lansung untuk menyokong penyataan
bahawa penduduk Kuala Muda sedang menuju kepada permerkasaan komuniti dan
bersedia untuk hidup bersama virus.

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RUJUKAN
Arwani, M. (2020,June). Menakar New Normal Desa. Rettrived from

Tribunjogja.Com
Mustangin, Kusiawati, D., Islami, N.P., Setyaninggrum, B., & Prasetyawati5, E.

(2017) Pemberbudayaan Masyarakat Berbasis Potensi Lokal Melalui
Program Desa Wisata Di desa Bumiji. Sosioglobal:Jurnal Pemikiran dan
peneitian Soiologi, 2(1), 59-72
Kieffer, C.H( 1984) Citizen Empowerment: a development perspective. Prevention
in Human Services, 3, 9-36
Tinjauan Amalan Norma Baharu oleh Institut Penyelidikan Tingkahlaku Kesihatan
pada bulan April - Julai 2020, Universiti Teknologi Mara pada Ogos 2020,
Bahagian Pendidikan Kesihatan pada November 2020 dan Institut
Penyelidikan Tingkahlaku Kesihatan semula pada Mei 2021. – Dipetik
daripada hasil Mesyuarat Jawatankuasa Eksekutif Pengurusan COVID-19
Bahagian Pendidikan Kesihatan 8 Julai 2021
Tinjauan Penerimaan dan Penolakkan Vaksin COVID -19 oleh Universiti Malaya
pada 3-12 April 2020, Institute Clinical Research pada 10 Julai – 31 Ogos
2020, Bahagian Pendidikan Kesihatan pada tahun 21-28 Disember 2020,
Universiti Sains Malaysia pada Januari 2021 dan Bahagian Pendidikan
Kesihatan tahun 2021. Dipetik daripada hasil Mesyuarat Jawatankuasa
Eksekutif Pengurusan COVID-19 Bahagian Pendidikan Kesihatan 8 Julai
2021
Hadri, L K (2018, Jan 30 ) Malaysia negara ke 9 paling aktif media social, ke 5
paling ramai guna e dagang.retrieved from https://www.astroawani.com/gaya-
hidup

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PREDICTORS OF COVID-19 BROUGHT-IN-DEAD CASES IN
KUALA MUDA DISTRICT

Suziana R.1, Eliana A.1*, Habshoh H.1, Hasniza H.1,
Nur Hashimah M.S.1 , Shazana R.A.2 , Nurul Anis R.1 , Nawal I.A.3, Shahizat R.4

1Pejabat Kesihatan Daerah Kuala Muda, 08000, Sungai Petani, Kedah.
2Institut Penyelidikan Perubatan, 50588, Kuala Lumpur.
3Pejabat Kesihatan Daerah Yan, 08800, Guar Chempedak, Kedah.
4Pejabat Kesihatan Padang Terap, 06300, Kuala Nerang, Kedah.

*Corresponding author: Eliana Ahmad, Pejabat Kesihatan Daerah Kuala Muda, 08000, Sungai
Petani, Kedah, [email protected]

ABSTRACT

Background: Kuala Muda District reported the first human-to-human transmission
of COVID-19 in Malaysia on 6th February 2020. High number of COVID-19 brought-
in-dead (BID) cases were reported in Kuala Muda from May to September 2021
during the pandemic. We aimed to determine the prevalence of BID among COVID-
19 deaths, to compare the characteristics between inpatient deaths and BID and to
determine the predictors of COVID-19 BID.
Methodology: We conducted a registry-based retrospective observational study of
COVID-19 deaths notified to Crisis Preparedness and Response Centre (CPRC)
Kuala Muda District Health Office between January 2020 and December 2021. 712
deaths reported during these period were analysed.
Results: The prevalence of BID among COVID-19 deaths in Kuala Muda were
14.9%. The proportions of cases who did symptomatic screening (45.7%) and
screening following contact to positive cases (33.5%) were significantly higher
among inpatient deaths. Age and presence of symptom(s) were found to be
predictors for BID. Those aged 31-40 years were 3.8 times more likely to be BID
(AOR 3.81, 95% CI 1.08, 13.58). Cases with symptoms were 48% less likely to be
BID than those who did not complaint of any symptom (AOR 0.52, 95% CI 0.27,
0.99).
Conclusion: Age and presence of symptom(s) appear to be significant predictors
for BID among COVID-19 deaths in Kuala Muda district with the latter shown to be
protective in preventing BID. Health education and health promotion on community
empowerment and health seeking behaviour should be tailored according to age
group and the emphasis on symptoms.

Keyword: COVID-19, COVID-19 deaths, brought-in-dead, inpatient deaths, vaccination

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INTRODUCTION

COVID-19 ongoingly exert great impact on the world since the cases of viral
pneumonia were reported in China back in December 2019. Public Health
Emergency of International Concern (PHEIC) was announced on 30 January 2020
by WHO before pandemic was declared in March 2020 due to the overwhelming
spread of cases, severity and inaction around the globe (WHO, 2020). As of 26
December 2021, WHO reported over 278 million cases and just under 5.4 million
deaths globally (WHO, 2021). Malaysia, let alone Kedah and Kuala Muda District
were not spared from being deeply affected by this pandemic. Malaysia has reported
2,758,086 cases as of 31 December 2021 with 29,091 deaths (MOH, 2021).

Kuala Muda District reported the first human-to-human transmission in Malaysia on
6th February 2020. The highest burden of both cases as well as COVID-19 deaths in
this district were seen between May 2021 and September 2021. COVID-19 deaths
reported in this district also showed high number of brought-in-dead (BID) cases. To
date, prevention and control activities for COVID-19 cases and deaths in Kuala Muda
have never been put on hold.

In this study, we aim to explore the predictors of COVID-19 BID cases in Kuala Muda
district. We would like to determine the prevalence of BID cases among COVID-19
deaths reported in Kuala Muda district while comparing the characteristics between
inpatient deaths and BID. The findings of this study will allow us to focus on changing
the outcome of interest, which is BID by targeting predictors that are hypothesized
to be causally related to the outcome through appropriate interventions.

METHODOLOGY

Data and Study design

We conducted a registry-based retrospective observational study of COVID-19
deaths notified to the Crisis Preparedness and Response Centre (CPRC) of Kuala
Muda District Health Office between January 2020 and December 2021. COVID-19
deaths followed the definition stated in COVID-19 Management Guidelines in
Malaysia No.5/2020 that classified death into Death due to COVID-19 and Death
with COVID-19. This is in line with the COVID-19 Death Classification Guidelines
issued by the World Health Organization (WHO) on April 16, 2020. Data was

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extracted from COVID-19 death registry from CPRC, Kuala Muda District Health
Office.

Study population

Study population for this study includes COVID-19 deaths (inpatient and BID) in
Kuala Muda district notified to CPRC Kuala Muda District Health Office from January
2020 until December 2021 and they were COVID-19 positive cases that have been
registered in Kuala Muda district. Deaths notified to CPRC Kuala Muda District
Health Office but not registered as cases in Kuala Muda were not included (exclusion
criteria). There were 712 deaths in Kuala Muda district notified to CPRC Kuala Muda
District Health Office during these period and all were cases registered in our district.
All 712 deaths were included in this study.

Study variables

Study variables include independent variables: age, sex, ethnicity, citizenship,
employment status, presence of symptoms, comorbidity status, symptoms’ onset to
death duration, vaccination status and CT (cycle threshold) Value. Dependent
variables measured in this study were inpatient deaths and brought-in-dead (BID).

Data analysis

Analysis was conducted using the Statistical Package of Social Science (SPSS)
software version 25 (IBM Corp, Armonk, NY). Data for continuous variables were
presented by mean ± standard deviation (SD). For categorical variables, frequencies
were calculated and presented together with percentages. Variables were compared
using the independent t-test for continuous variables and the Chi-squared or Fisher’s
exact (n≤5 in any cell) test for categorical variables. Simple and multiple logistic
regression were used to determine the significant predictors for BID. Only
independent variables with p value <0.25 and/or regarded as clinically important
from the univariate analysis (simple logistic regression) were included in the final
model. All statistical tests were two-sided and used a significance level of 0.05.

RESULTS
Kuala Muda District reported a total number of 44,867 COVID-19 cases for the
period between 1st January 2020 and 31st December 2021 with 712 COVID-19

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deaths (death due to COVID-19 and death with COVID-19). 1 death was reported in
year 2020 (Figure 1).

COVID-19 CASES AND DEATHS REPORTED FROM EPID WEEK 1 TO
EPID WEEK 52 2021 (3 JANUARY 2021- 1 JANUARY 2022) IN KUALA

MUDA DISTRICT

3500 CAC walk-in Vaccination 100
3000 strategy initiated coverage for adults: 90
2500 80% (dose 1) and 80
2000 70
1500 50% (dose 2). 60
1000 50
No.of Cases 40
500 No.of Deaths30
0 20
10
0

Epid Week 1
Epid Week 3
Epid Week 5
Epid Week 7
Epid Week 9
Epid Week 11
Epid Week 13
Epid Week 15
Epid Week 17
Epid Week 19
Epid Week 21
Epid Week 23
Epid Week 25
Epid Week 27
Epid Week 29
Epid Week 31
Epid Week 33
Epid Week 35
Epid Week 37
Epid Week 39
Epid Week 41
Epid Week 43
Epid Week 45
Epid Week 47
Epid Week 49
Epid Week 51

COVID-19 Cases Reported Inpatient Deaths BID

Figure 1: COVID-19 cases and deaths reported from Epid Week 1 to Epid Week 52
2021 (3 January 2021 to 1 January 2022 in Kuala Muda district).

The prevalence of BID among COVID-19 deaths were 14.9%. Table 1 below
described the characteristics of COVID-19 deaths according to type of deaths
(inpatient deaths and BID cases). 57.5% of all BID cases were among males. The
mean age of BID cases were 57.3 years and 28.3% occurred among those aged 70
years and above followed by those aged between 51 to 60 years at 20.8%. However,
in comparison to inpatient deaths, the proportions of BID cases were significantly
higher among those aged 30 years and younger, 31 to 40 years and more than 70
years old. There were 3.8% of BID cases that involved non-citizens. 67% of all BID
cases were among Malays, followed by Chinese (16.0%) and Indians (13.2%).
Nonetheless, among the Chinese, the proportion of BID cases was significantly
higher compared to inpatient deaths.

In terms of presence of symptoms, 23.6% of all BID cases did not present with any
symptoms and the proportion was significantly higher compared to inpatient deaths

60

whilst the proportions of cases who died in hospital and presented with symptoms
were significantly higher compared to BID cases (88.8%). There were no significant
differences in the durations from symptoms’ onset to death for both BID cases and
inpatient deaths (BID=Mean days 21.0 ± 12.4, Inpatient=Mean days 19.1 ± 11.8, P
value 0.130). There were no significant differences in the proportions of BID cases
and inpatient deaths among those who have completed vaccination, partially
vaccinated or not vaccinated at all with any type of COVID-19 vaccination. We also
looked into the screening category where the cases were first diagnosed with
COVID-19 before they died. The proportions of cases who underwent symptomatic
screening (45.7%) and screening following contact to positive cases (33.5%) were
significantly higher among inpatient deaths compared to BID cases. 61.3% of all BID
cases were only found to be positive when they were screened in the forensic
department since deaths that occurred outside hospitals need to be referred to the
forensic department before any autopsy decision was made.

Table 1: Characteristics of COVID-19 deaths according to type of death.

Characteristics All Type of Death P value
N (%) N (%)
Sex BID Inpatient
Male (N=106) (N=606)
Female
370 (53.1) 61 (57.5) 317 (52.3) 0.319a
Age (years) (Mean ± SD) 334 (46.9) 45 (42.5) 289 (47.7) 0.147c
Age group (years) 59.6 ± 15.3 57.3 ± 18.1 60.0 ± 14.7

≤ 30 38 (5.3) 8 (7.5) 32 (5.3) 0.002a
31-40 47 (6.6) 16 (15.1) 31 (5.1)
41-50 99 (13.9) 10 (9.4) 89 (14.7)
51-60 166 (23.3) 22 (20.8) 144 (23.8)
61-70 177 (24.9) 20 (18.9) 157 (25.9)
>70 183 (24.9) 30 (28.3) 153 (25.2)
Citizenship
Malaysian 700 (98.3) 102 (96.2) 598 (98.7) 0.088b
Non-Malaysian 8 (1.3)
Ethnicity 12 (1.7) 4 (3.8)
Malay
Chinese 503 (70.6) 71 (67.0) 432 (71.3) 0.027b
Indian 77 (10.8) 17 (16.0) 60 (9.9)
Nepal 118 (16.6) 14 (13.2)
Indonesian 104 (17.2)
Bangladesh 4 (0.6) 0 (0.0) 4 (0.7)
Others 4 (0.6) 3 (2.8) 1 (0.2)
Employment status 4 (0.6) 1 (0.9) 3 (0.5)
2 (0.3) 0 (0.0) 2 (0.3)

61

Unemployed 511 (71.8) 77 (72.6) 434 (71.6) 0.829b
Employed 201 (28.2) 29 (27.4) 172 (28.4) 0.276a
Comorbidity status <0.001a
No 227 (31.9) 29 (28.7) 198 (34.3) 0.130c
Yes 452 (63.5) 72 (71.3) 380 (65.7) 0.653a
Presence of symptom(s)
No 93 (13.1) 25 (23.6) 68 (11.2) <0.001a
Yes 619 (86.9) 81 (76.4) 538 (88.8)
Symptoms’ onset to death 0.130c
duration (days) (Mean ± SD) 19.4 ± 11.9 21.0 ± 12.4 19.1 ± 11.8
Vaccination status
Unvaccinated 476 (66.9) 77 (74.0) 399 (70.1)
1 dose (partial) 108 (15.2) 16 (15.4) 92 (16.2)
Completed 2 doses 89 (12.5) 11 (10.6) 78 (13.7)
Screening category
Cluster 53 (7.4) 2 (1.9) 51 (8.4)
SARI 30 (4.2) 0 (0.0) 30 (5.0)
Symptomatic 291 (40.9) 14 (13.2) 277 (45.7)
EMCO 7 (1.0) 2 (1.9) 5 (0.8)
Death 70 (9.8) 65 (61.3) 5 (0.8)
Self-screening 1 (0.1) 0 (0.0) 1 (0.2)
Close contact 224 (31.5) 21 (19.8) 203 (33.5)
Pre Admission 32 (4.5) 2 (1.9) 30 (5.0)
Workplace 4 (0.6) 0 (0.0) 4 (0.7)
CT Value (PCR) (Mean ± SD) 22.4 ± 6.1 23.2 ± 6.8 22.3 ± 6.0

P-values <0.05 are considered statistically significant
a P-values derived from Pearson Chi Square test
b P-values derived from Fisher Exact Square test
c P-values derived from Independent T-Test
Missing data: Age = 3 inpatient; Comorbidity = 5 BID and 28 inpatient; Vaccination status = 2 BID
and 37 inpatient; Symptom’s onset to death duration = 2 BID and 1 inpatient; Positive to death

duration = 1 BID and 10 inpatient; CT value = 11 BID and 91 inpatient

Table 2 explained the association between each independent variable with BID. In
univariate analyses (using simple logistic regression), only presence of symptom
was found to be significantly associated with BID. Those with symptoms were 59%
less likely to be brought in dead than those who did not complaint of any symptom
(OR 0.41, 95% CI 0.25, 0.69). Multiple logistic regression analyses were conducted
to identify significant predictors for BID. The model was built by including
independent variables with P value of <0.25 from univariate analyses and/or
variables regarded as clinically important. Other than independent variables found
to be significant from univariate analyses, six variables that fulfilled the criteria stated
above were included in the model: age, citizenship, morbidity status, vaccination
status, symptom’s onset to death duration and CT value.

62

Table 2: Univariate and multivariate analysis of predictors of BID.

Variables Univariate Analysis Multivariate Analysis

Sex OR (95% CI) P value AOR (95% CI) P
Male value
Female
-
Age group (years)
≤ 30 Reference
31-40
41-50 0.81 (0.53 – 1.23) 0.319
51-60
61-70 Reference
>70
2.07 (0.77 – 5.51) 0.148 3.81 (1.08 – 13.58) 0.038*
Citizenship 0.76 (0.20 – 2.85) 0.681
Non-Malaysian 0.45 (0.16 – 1.24) 0.122
Malaysian - -
0.61 (0.25 – 1.50) 0.281 1.03 (0.32 – 3.35) 0.966
Ethnicity 1.53 (0.48 – 4.85) 0.469
Non-Malay 0.51 (0.21 – 1.26) 0.144
Malay
0.78 (0.33 – 1.87) 0.583
Comorbidity status
No Reference
Yes
0.34 (0.10 – 1.15) 0.084 0.51 (0.10 – 2.55) 0.413
Presence of -
symptom(s)
Reference
No
Yes 0.82 (0.53 – 1.27) 0.370
Vaccination status
Unvaccinated Reference
1 dose
Completed 2 1.30 (0.81 – 2.06) 0.277 1.32 (0.79 – 2.21) 0.292
doses
Symptoms’ onset to Reference
death duration
(days) 0.41 (0.25 – 0.69) 0.001 0.52 (0.27 – 0.99) 0.049*
CT Value (PCR)
Reference

0.90 (0.50 – 1.62) 0.727 0.86 (0.46 – 1.62) 0.648
0.65 (0.28 – 1.53) 0.328
0.73 (0.37 – 1.44) 0.364 0.620
1.00 (0.98 – 1.03)
1.01 (1.00 – 1.03) 0.130 1.01 (0.98 – 1.05) 0.486
1.02 (0.99 – 1.06) 0.199

In the final regression model, only two variables emerged as significant predictors
for BID; age and presence of symptom(s). Those aged 31-40 years were 3.8 time
more likely to be brought in dead than those aged 30 years and below (AOR 3.81,
95% CI 1.08, 13.58). Cases with symptoms were 48% less likely to be brought in
dead than those who did not complaint of any symptom (AOR 0.52,
95% CI 0.27, 0.99).

63

DISCUSSIONS

In this study, we specifically described the predictors of COVID-19 BID in Kuala
Muda district that was reported from January 2020 to December 2021. In 2020, only
1 inpatient death was reported in Kuala Muda and we have seen 711 deaths in year
2021 with the prevalence of BID cases at 14.9%. During the crisis within the
pandemic that took place in Kuala Muda between May 2021 and September 2021,
Kuala Muda reported 35,859 COVID-19 cases with 665 COVID-19 deaths within this
period. We had a 7-day average of cases reaching the peak between 400-500 cases
daily from August to September before it started to plateau in October 2021. The
peak of deaths occurred in July 2021 with a mortality rate of 2.6% and the highest
number of COVID-19 BID cases ever reported in this district. This COVID-19 crisis
within the pandemic that occurred during this period greatly impacted Kuala Muda
District Health Office’s capability in terms of disease control and prevention of deaths
especially COVID-19 BID.

Age and presence of symptom(s) appeared to be the predictors of COVID-19 BID in
Kuala Muda. This study has shown that young people aged between 31 to 40 years
old with no COVID-19 symptom(s) have a higher risk for COVID-19 BID. These two
unique findings explain the importance of recognizing symptoms of COVID-19
infection in order for individuals to be tested and detected early for COVID-19 and
hence prompt treatment can be offered. Being young in the productive age group
probably made these individuals more occupied with their daily chores and make
them less aware of the symptoms or did not realize that they are having symptoms
especially if the symptoms are in the mild form. Therefore, the rapid progress of the
disease (especially during the spread of Delta VOC) has lead to late detection and
death outside the healthcare system and thus, having symptoms is a protective
factor for COVID-19 BID. This could also be explained by 88.8% of inpatient deaths
whom had symptoms before they were confirmed with COVID-19 infection, and
higher proportion of these inpatient deaths did symptomatic screening and went for
COVID-19 testing once they had contact with positive cases.

Presence of comorbidity could be one of the reason for a person to get tested for
COVID-19, especially if they had history of exposure and were in contact with
positive cases, although in the absence of symptoms. In the prevention and control
strategy of COVID-19 in Malaysia, a person with comorbidity is regarded as high risk
if they acquire COVID-19 infection, thus they will be prioritized for COVID-19
infection screening.

64

In this study, presence of comorbidity and number of comorbidities were not proved
to be associated with BID. This in part maybe due to the analysis that was conducted
in this study, which looked into the comparison between BID and inpatients deaths.
Many studies looking into the predictors of COVID-19 deaths were done among
those who died in comparison to those who survived. Comorbidities and the number
of comorbidities the cases had were critical factors in predicting deaths especially
among the elderly and among cases who died compared to cases who survived from
the infection (Casas-Deza et al., 2021; Chen et al., 2020; Tian et al., 2020;
Williamson et al., 2020). This study had also showed 63.5% of all deaths had at least
one comorbidity, despite being not significantly associated with BID.

Health-seeking behaviour is a pertinent component to be highlighted following the
findings on the two predictors for COVID-19 BID in Kuala Muda district. Poor health-
seeking behaviour has been associated with increased morbidity and mortality whilst
seeking early treatment has been reported to result in more favourable health
outcomes (Latunji & Akinyemi, 2018). Despite the ongoing and continuous, intensive
and culturally-tailored health promotion activities focusing on COVID-19 symptoms
and the necessity to get tested for COVID-19 in Kuala Muda; it might have not
reached everyone equally. Those in the working age group might experience mild
symptoms that could possibly have been disregarded or neglected and could lead
them to be undiagnosed leading to COVID-19 BID. Having said that, factors
including geographical, social support and cultural factors were never measured in
this study. These are among the factors that could also possibly explain COVID-19
BID among these group (Latunji & Akinyemi, 2018). In addition to that, utilization of
healthcare services among those aged 31 to 40 years old during the pandemic crisis
might have been influenced by limited knowledge and information about the disease,
perception towards the illness and stigma (Chileshe et al., 2020).

CONCLUSION

Age and presence of symptom(s) appear to be significant predictors for brought-in-
dead cases among COVID-19 deaths in Kuala Muda district. Health education and
health promotion in terms of community empowerment, especially on health seeking
behaviour for prevention and control of COVID-19 infection and deaths in Kuala
Muda district; should be tailored according to age group with specific emphasis on
symptoms. Presence of symptom(s) have been shown to be protective in the
prevention of COVID-19 BID.

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ACKNOWLEDGEMENT

We would like to thank Kedah State Health Department, Crisis Preparedness and
Response Centre of Kedah State Health Department, Crisis Preparedness and
Response Centre of Kuala Muda District Health Office and each and everyone in
COVID-19 team of Kuala Muda District Health Office for their endless support and
dedication. The authors would like to thank the Director General of Health Malaysia
for his permission to publish this paper.

REFERENCES

Casas-Deza, D., Bernal-Monterde, V., Aranda-Alonso, A. N., Montil-Miguel, E.,
Julián-Gomara, A. B., Letona-Giménez, L., & Arbones-Mainar, J. M. (2021).
Age-related mortality in 61,993 confirmed COVID-19 cases over three
epidemic waves in Aragon, Spain. Implications for vaccination programmes.
Plos one, 16(12), 1932-6203.

Chen, T., Wu, D. I., Chen, H., Yan, W., Yang, D., Chen, G., . . . Wang, H. (2020).
Clinical characteristics of 113 deceased patients with coronavirus disease
2019: retrospective study. bmj, 1756-1833.

Chileshe, M., Mulenga, D., Mfune, R. L., Nyirenda, T. H., Mwanza, J., Mukanga, B.,
. . . Daka, V. (2020). Increased number of brought-in-dead cases with COVID-
19: is it due to poor health-seeking behaviour among the Zambian population?
The Pan African Medical Journal, 37.

Latunji, O. O., & Akinyemi, O. O. (2018). Factors influencing health-seeking
behaviour among civil servants in Ibadan, Nigeria. Annals of Ibadan
postgraduate medicine, 16(1), 1597-1627.

MOH. (2021). covidnow.moh.gov.my.
Tian, W., Jiang, W., Yao, J., Nicholson, C. J., Li, R. H., Sigurslid, H. H., . . . Malhotra,

R. (2020). Predictors of mortality in hospitalized COVID‐19 patients: a
systematic review and meta‐analysis. Journal of medical virology, 92(10),
0146-6615.
WHO. (2020). Novel Coronavirus (2019-nCoV) SITUATION REPORT - 1 21 January
2020

WHO. (2021). Weekly epidemiological update on COVID-19 - 28 December 2021.

Williamson, E., Walker, A. J., Bhaskaran, K., Bacon, S., Bates, C., Morton, C. E., . .
. Inglesby, P. (2020). Factors associated with COVID-19-related hospital
death in the linked electronic health records of 17 million adult NHS patients.
MedRxiv.

66

COVID-19 ASSESSMENT CENTER (CAC) OF KUALA MUDA,
KEDAH: TRANSIT BAY IN CAC- A SAVIOR IN CRISIS
MANAGEMENT DURING COVID-19 PANDEMIC

Nur Hashimah M.S1.,Habshoh H1.,Hasniza, H1,Suziana R2, Eliana A2.

1Covid-19 Assessment Center (CAC) Kuala Muda, Kedah
2Pejabat Kesihatan Daerah Kuala Muda, 08000, Sungai Petani, Kedah.
*Corresponding author: Nur Hashimah Mat Saad, Kuala Muda CAC, PKD Kuala Muda, Jalan
Badlishah, 08000 Sg Petani, Kedah, Malaysia, [email protected]

__________________________________________________________________

ABSTRACT
Background: Covid-19 Assessment Centre (CAC) of Kuala Muda, Kedah is one of the
213 CAC nationwide that has been established by the Ministry of Health Malaysia (MOH)
in response to high numbers of patients during the third wave of Covid-19 crisis in early
January 2021. Kuala Muda CAC is located at Dewan Kenanga PKD Kuala Muda and
started its operation on 17th January 2021. The main function of the CAC is to conduct
risk and clinical status assessments on Covid-19 patients to determine whether such
patients can be allowed to perform self-isolation at home or need hospitalization.

Methodology: In the beginning, Kuala Muda CAC followed the MOH standard operating
guideline in managing Covid-19 cases. As the Covid-19 cases kept increasing, Kuala
Muda CAC had to modify its function to cater to patients’ needs.
A transit bay was set up at Kuala Muda CAC to give early treatment and observe the
patients while waiting for their beds in the hospital. The long waiting time for admission
to the ward is the main reason for the transit bay to be established.

Result: Based on our observation, the transit bay had its strong point and weaknesses.
The main advantage of establishing the transit bay in CAC is being able to provide
immediate and quick medical attention to the patients after evaluation sessions by the
medical officers. Shortcomings were confronted too during setting up the transit bay.
Those included lack of manpower, infrastructure, patient management, and social
welfare of the patients at the transit bay.

Conclusion: CAC Kuala Muda had to change the original function which was initially
evaluating the Covid-19 case and later giving early treatment to Covid-19 patients who
were in an unstable condition. Although transit bay was established in a state of scarcity,
it has been a savior in ensuring Covid-19 patients received early treatment before being
sent to the hospital during the crisis.

Keywords: Covid-19, Covid-19 Assessment Center, Early treatment, & transit bay

67

INTRODUCTION

In the beginning, when Covid-19 cases were first detected in Malaysia in February
2020, all cases were admitted to government hospitals or quarantine centers
regardless of the patient category. In Kuala Muda, the total number of cases
recorded from the beginning of February 2020 till the end of 2020 was only 230
cases and all of them have been admitted to hospitals and quarantine centers for
further treatment and monitoring.

When the third wave of Covid-19 hit Malaysia in September 2020, all states
especially Selangor and Sabah had overwhelming number of Covid-19 patients that
needed immediate medical attention. When this happened, the Ministry of Health of
Malaysia (MOH) had to take drastic action by introducing a new service: Covid-19
Assessment Centre (CAC).

BACKGROUND

Covid-19 Assessment Centre (CAC) is a new service created by the Ministry of
Health of Malaysia in the face of the Covid-19 pandemic. The sharp increase in daily
Covid-19 cases in early 2021 led to the establishment of CAC to assist and support
the burden of admissions of patients to hospitals and quarantine centers.
Furthermore, 85 percent of the total Covid-19 cases were not life-threatening and
were allowed to be quarantined and monitored from home (Abdullah, 2021).

The Ministry of Health Malaysia (MOH) established a total of 213 COVID-19
Assessment Centers (CAC) nationwide to conduct assessments on COVID-19
patients undergoing home treatment in January 2021 (Arumugam, 2021). Of all the
CAC centers, 11 were established in Kedah in each district and each center has
administrator from respective Health District Offices. The CAC Kuala Muda is
headed by a District Coordinator, Public Service Premiere Post Family Physician
(Gred Khas Jusa C), and assisted by Liaison Officer and Medical Officer (UD54).
Kuala Muda CAC operates centrally starting on 17 January 2021. It is located at
Dewan Kenanga, PKD Kuala Muda nearby Covid 19 Command Centre of District
Health Office. The location of the center is strategic as it is connected to the main
road of the Sungai Petani town and has plenty of access to open spaces.

The main function of the CAC is to conduct risk and clinical status assessments on
Covid-19 patients. This is to determine whether such patients can be allowed to
perform self-isolation at home or need to be hospitalized. The CAC also serves to
run Home Surveillance daily on cases that undergo self-isolation at home using
Home Assessment Tool. Through Home Surveillance, CAC can identify any patient
who is at risk of disease progression and need to be referred to the hospital.

68

Apart from that, CAC received step-down cases from hospitals and quarantine
centers to be monitored at home until patients finish their quarantine period.

Dewan Kenanga was a former dining hall of a nursing hostel and it is a double-story
building. Rooms at Dewan Kenanga have also been renovated into a clinical space,
and data management facility. Each room is provided with medical and non-medical
equipment facilities. Most importantly, all rooms are fully equipped with internet
connection essential in carrying out Kuala Muda CAC activities.

In the early stages of its establishment, all medical staff were placed at Dewan
Kenanga. The workforce comprised of ten personnel from various categories of
medical staff from the health clinics under the Kuala Muda District Health Office.
They were given a strict schedule and took turns on daily basis.

Kuala Muda CAC active operation is from 8.00 am to 5.00 pm, Sunday to
Wednesday, 8.00 am to 3.30 pm on Thursday; and on public holidays and
weekends, the CAC operates from 8 am to 1 pm. However, there is on-call medical
officer and on-duty staff to accommodate any problem outside working hours. Within
24 days of the first month, Kuala Muda CAC operationally had seen 351 active
Covid-19 cases.

THE ESTABLISHMENT OF THE CAC KUALA MUDA TRANSIT BAY

At the beginning of its establishment, Kuala Muda CAC did not immediately provide
any facility to offer early treatment to patients who came for the initial assessment.
We adhered to guidelines given by MOH. If any patients required admission to the
hospital, the patient would be referred without a long wait to get a bed. Most of the
patients referred to the quarantine centre were stable patients and they could wait
at home before being transported on the same day.

Figure 1 shows a marked increase in the total attendance to Kuala Muda CAC from
May 2021 (2161) to August 2021 (12327). This is in line with total Covid-19 positive
cases in Malaysia between 17,000 and 20,000 new infections daily with the highest
registered on August 20 at 23, 564 (Adnan, 2021). In line with the large increase in
Covid-19 cases nationwide, MOH changed CAC work procedures by looking at
symptomatic and high-risk cases only and implementing the CAC virtually in July
2021 (Keong, 2021).

69

TOTAL ATTENDANCE OF COVID 19 CASES TO CAC KUALA
MUDA 2021

25000

20000

NUMBER 15000

10000

5000

0 Jan Feb March Apr May June July Aug Sept Oct Nov Dec
203 320 132 181 863 2411 4074 10444 9281 2792 2454 2149
Discharge 351 929 145 459 2161 3009 7448 12327 7412 2875 2472 2244
CAC Assessment

Figure 1. Total attendance of positive Covid-19 cases to Kuala Muda CAC from 17th
January 2021 to 31st December 2021

Still, Kuala Muda CAC still encourages all positive Covid-19 patients to come for
physical assessment. This is because many patients still do not have access to the
internet for virtual CAC. Patients who are asymptomatic and at low risk are still asked
to be physically present to be given home quarantine advice by medical officers
before being given a home surveillance order (HSO) form by a public health
assistant. We also carried out an assessment of vital signs on patients who were
symptomatic and had various risks of disease (comorbidity).

In Figure 2, it shows a rising trend of cases referred to hospitals and quarantine
centers from May 2021 to August 2021. This happened during the third wave when
the Delta Variant of Concern (VOC) hit and Covid-19 patients presenting with more
severe symptoms (Ong et al. 2021). In Figure 3, the data shows the increase in
Covid-19 Category 4 cases seen at Kuala Muda CAC starting from May 2021 and
peaked in August 2021. Covid-19 Category 4 cases and above required oxygen
treatment and need further treatment in hospitals. At this point, the bed usage in
hospitals in Kedah had reached its maximum capacity. From the State Command
Centre report in July and August 2021, the total bed occupancy rate (BOR) for Covid-
19 cases in Kedah has reached 97 percent (Rahman, 2021). Although there had
been an increase in bed numbers as more hospitals started to accept Covid-19
cases, such as Yan Hospital and Sik Hospital, the bed usage rate at both hospitals
had also reached 80 percent (Hamid, 2021).

70

NUMBER OF PATIENTS REFERRED TO HOSPITAL/PKRC &
QUARANTINE AT HOME 2021

12000
10000

Number 8000

6000

4000
2000

0 Feb March Apr May June July Aug Sept Oct Nov Dec
17-31
Jan 456 57 178 1712 2243 6341 11217 6872 2549 2260 1990
399 48 99 230 274 452 521 284 94 80 70
HQ 221 116 39 178 212 485 650 582 292 222 122 184
HOSP 81
PKRC 49

Figure 2. The outcome of Assessment in Kuala Muda CAC.

NUMBER OF CATEGORY 4 CASES REPORTED IN CAC KUALA
MUDA 2021

350

300

250

200

150

100

50

0
Jan Feb March Apr May June July Aug Sept Oct Nov Dec

CAT 4 0 0 0 0 10 53 220 301 99 20 13 11

ED admission 0 0 0 0 10 8 54 28 4 1 1 0

CAT 4 ED admission

Figure 3. Number of Category 4 Cases Reported in CAC Kuala Muda 2021

The full bed occupancy in the hospital had caused congestion and it was impossible
for the hospital to receive new cases from the Emergency Department (ED) or
referrals from the CAC. Existing patients in wards receiving treatment were still not

71

able to be allowed to return home. This had delayed the process of admission of
new cases to the wards. Other than full inpatient beds, the hospital's Emergency
Department was overwhelmed with many cases still waiting for admission to the
ward and could not cope with the referral from the CAC due to lack of oxygen point.

METHODOLOGY

INTRODUCING THE TRANSIT BAY

Figure 4. Early days of transit bay

Early May 2021, when Kuala Muda started to report cases more than 100 cases per
day, CAC had initiated and built an outdoor instant center coined “transit bay” to
observe these patients before they were sent to the hospital. It had to be done
because the waiting time to admit these patients to the hospital were very long.
Usually, the waiting time is around one to two hours but when the number of cases
had increased, the waiting time became longer. Initially, the transit bay was set up
under a tent and there were only two beds with two canvas made available to cater
to these stranded patients. As the cases kept increasing especially during the peak
time in July and August 2021, we expanded the transit bay by installing another tent
and we further added four hospital beds, and four lazy chairs.

The transit bay was equipped with basic medical equipment such as an emergency
trolley, standing blood pressure monitor, drip stands, and oxygen tank. We also
placed a whiteboard at the transit bay for Medical Assistants (MA) to record patients
who entered into and walked out of the tent. The whiteboard was also used to record
and update the patient's condition throughout the monitoring period. While the CAC
received many patients who needed admission to the ward and needed to be given
early treatment, one MA had been stationed at the transit bay at one time and was
assigned on rotation every two to three hours. CAC needed a minimum of three MAs
to be on rotation daily at that time.

72

MA’s task at transit bay was to provide early treatment as directed by the on duty
doctor or so called Medical Officer (MO) and monitor the patient's condition before
being sent to the hospital. He would also update the patient's condition to MO on-
call throughout the observation period using a walkie-talkie. Their task is complete
when all patients under the tent had been sent to the hospital.

Figure 5. Transit bay with tents, minimal beds, and chairs

FINDINGS
WORKFLOW AT THE TRANSIT BAY TENT OF KUALA MUDA CAC
To ensure the transit bay operates smoothly during a hectic day, we have introduced
the workflow for all medical staff to adhere. Here is the simple workflow of the transit
bay (Figure 6)

DISCUSSION ON BENEFITS, CHALLENGES, AND LIMITATIONS
Even though Kuala Muda CAC transit bay faced several rough challenges during its
operational period but it had successfully thrived in assisting and providing early
treatment to Covid-19 patients.

Immediate and quick medical attention
After being assessed by MO, patients who needed early medical attention will be
taken to transit bay. MO and paramedics were ready to provide immediate treatment
without delay. There have been several occasions encountered when patients need
to be resuscitated at the transit bay before being sent to the Emergency Department
in hospital. Continuous monitoring by the MA in transit bay will help detect early signs
of deterioration in patients while waiting for beds in the hospital. If the patient’s
condition worsened, we sent the patient straight away to casualty (ED). Despite
being built in a state of deprivation, staff at the CAC are committed to offer the best
possible service for all Covid 19 patients with their sense of responsibility and trust

73

as health personnel. We have encountered some challenges at the transit bay.
These can be seen as the followings:

MO evaluate
patient

Patient suitable Patient require
for admission to hospital

Home
quarantine

Patient stable but Patient unstable
need early
treatment

HAT MO on call refer Refer ED
physician on duty HSAH
MO Inform MA at
transit bay

HSO MA booking bed Treat & observe
in ward at transit bay

Bed available while waiting for
bed

MA update MO oncall
– patient condition

Send patient to
ward

Figure 6. Workflow of transit bay at CAC Kuala Muda

74

Manpower
When the Covid-19 cases rose, the number of medical officers also had to be
increased by almost 20 people per day as the highest number of active cases
reached 731. Many staffs were mobilized from clinical support positions such as
pharmacists, staff restorers, occupational therapists, X-Ray department, counselors
and administrative officers from the Kuala Muda District Health Office.

Later, during the month of July 2021, the health clinic staff had to be mobilized to
manage Enhanced Movement Control Order (EMCO) also known as “PKPD” at two
residential areas. Both areas, Taman Bandar Baru Sg Lalang and Taman Cahaya
which are located in Kuala Muda which are heavily populated area. That lead to
staff shortage in CAC to monitor the patients’ critical condition. To assist with the
situation, other district health offices extended their aid and support. During this
period, all non-critical services at clinics were suspended temporarily to provide
mobilization capability for support personnel to assist at the CAC. This is because,
in transit bay, the CAC needs a minimum of three MAs to be on rotation daily at that
time. At the same time, the MA would also be given the task to send patients to
hospitals and quarantine centers. Not only that, the Kuala Muda CAC had to endure
long operation hours during the peak periods of July and August 2021. Kuala Muda
CAC actively operates almost 16 hours a day to ensure that Covid-19 patients can
be assessed by medical officers.

Staff shortages at CAC also occurred when some of the staff contracted Covid-19
infection and close contacts of Covid-19 patients had to be quarantined for 10 to 14
days. To reduce human resource problem in dealing with the pandemic, the District
Health Officer had to issue a rest leave-freeze order to all health personnel in the
Kuala Muda district except for emergency reasons. All focus was on Covid-19
screening and Covid-19 positive case management.

Amenity
Transit bay of Kuala Muda CAC was formed initially using a single tent outside of
the Dewan Kenanga building before it was later expanded to two tents. Using tents
as transit bay cause extreme discomfort to the patients. During extreme hot weather
and rainy day, patients had to endure the heat and damp while waiting for a long
time under the tent. Not only that, the use of tent had exposed patients and staff to
safety hazards since the tent may collapse during windy weather or heavy rain.

Poor ventilation at the transit bay was another challenge. However, CAC managed
to get donations from various generous individuals in which they donated industrial
fans that have been placed underneath the tents. These fans helped to improve
ventilation and alleviate patients’ restlessness. Medical equipment is also a major
issue during the expansion of the transit bay tents. During the initial CAC
establishment, Covid-19 was at its peak. All hospitals, emergency departments, and

75

clinics were fully utilizing medical equipment around the clock. As CAC needed
medical equipment immediately, we received generous aid. Equipment such as
blood pressure machines, glucometers, pulse oximeters, emergency trolleys, and
other non-medical items was provided by the district health office with the help of
other government agencies such as the Jabatan Kerja Raya (JKR), municipal
authority such as Majlis Perbandaran Sungai Petani (MPSP). Donations from private
companies such as PETRONAS, Tenaga Nasional Berhad (TNB), Syarikat HASANI,
and charity organizations such as Tsu Zhi, SALIMA, and Malaysian Relief Agency
(MRA) Kedah started to pour in for both medical and non-medical equipment during
the critical time.

Management of patients
Kedah State Health Department (JKN) has issued guidelines on the management of
Covid-19 patients and case management at CAC (7). During the Covid-19 pandemic
crisis period, the CAC had to change the management of patients due to
overcrowding in hospitals. The existing guidelines could not be fully complied with.
Patients are assessed individually by MO and if they were stable, they were allowed
to resume quarantine at home. If necessary, some patients were asked to come the
next day for reassessment at the CAC.

Patient management at transit bay also had to be changed when there were too
many patients under the tent. There was a time when we needed to prioritize the
patients who were waiting at the transit bay. Patients with stable vital signs were
asked to wait at home until their beds were ready. Patients who needed oxygen but
showed stable vital signs could be observed at the transit bay while unstable patients
were sent immediately to casualty.

Social welfare of patients
Another issue to be highlighted is patients’ welfare at the transit bay. Basic amenities
such as patients’ meals and toilets are still a major problem at the transit bay. While
the patients wait under the tent for an extended period of time, they could not access
warm meals. Facilities such as food kiosks or cafes which are similar to the hospital
are not available. CAC was only able to provide packed biscuits and mineral water
for patients at that time. If we received food donations from outside parties, we
shared with patients waiting at transit bay. Some had to call family members to
deliver food to feed their hunger during that time.

The transit bay is located outside the Dewan Kenanga building. As an outdoor and
instant center, the transit bay has no toilet and washbasin. Medical staff and patients
can only access the toilet indoor which is in the building - Dewan Kenanga. Due to

76

that, patients had to walk rather a long distance from the MO check-up zone. Not
only the patients were already weak to move, but some patients might also need
assistance since they were on a wheelchair to get to the toilet.

UNTOLD STORIES
Throughout the operation of the transit bay, valuable experiences and remarkable
best practices are obtained. Some of the untold moments were worth being
cherished and it had taught precious values and lessons to all Kuala Muda CAC
officers. The first case occurred when our team gave Cardiopulmonary Resuscitation
(CPR) on the morning of July 18, 2021. A Chinese gentleman came to CAC with
respiratory collapse and was resuscitated by the managing team. With the limited
equipment we had and the patient’s severe condition, the patient was unable to
survive. He was pronounced dead at Kuala Muda CAC and was sent to hospital for
post mortem.

The next experience happened when the transit bay was fully swarmed with patients.
These patients needed oxygen therapy and there were times that the supply was
dreadfully inadequate. During that time, the oxygen supply from the procurement
company was extremely low throughout the country, and there were high usage and
demand for oxygen while patients were waiting. Consequently, MO had to make
difficult decisions at times in prioritizing which patient needed oxygen more. During
a bad and crowded day, we needed to make some changes to the tubing so that
patients could share the oxygen supply. It was very devastating but we had limited
options.

RECOMMENDATIONS
Transit bay of Kuala Muda CAC had been transformed to become more or less an
observation ward or mini emergency department during the Covid-19 crisis.
Nevertheless, due to inadequate staff and equipment, it faced numerous glitches but
it could offer more crucial services and procedures in CAC. In the future, if such a
situation recurs, the transit bay should be established in the compound of a hospital
near the Emergency Department. The transit bay should be placed under medical
supervision with more expertise rather than being under the public health
administration.

CONCLUSION
The Covid-19 pandemic has caused many abrupt changes in primary health care.
The CAC was established to help address the shortage of hospital beds by providing
an assessment before Covid-19 patients were allowed home quarantine. With a
sudden increase in cases and a shortage of beds in hospitals, the CAC had to modify

77

its original function from Covid-19 case evaluation to giving early treatment to Covid
19 patients who were in unstable conditions. Apart from the cooperation and high
commitment from all levels of positions at the Kuala Muda District Health Office, most
government agencies and external parties have been very cooperative with the
management of Kuala Muda CAC during the Covid-19 pandemic.

ACKNOWLEDGEMENT
We would like to extend our deepest gratitude to our District Health Office and the
involvement of government departments such as the Public Works Department or
Jabatan Kerja Raya (JKR), Sungai Petani City Council (MPSP), private companies
such as PETRONAS, TNB, Syarikat HASANI as well as charitable and voluntary
organizations such as Tsu Zhi, SALIMA Kedah, and MRA Kedah. They have
contributed not only monetary aid but also the equipment to meet our current needs.
Tent borrowing and installation were set up immediately to provide comfort to
growing patients. We have received enormous donations in the form of medical
equipment such as pulse oximeter, blood pressure level screening sets, glucometer
machines, thermometers, and oxygen concentrators to help monitor the patient at
the transit bay. Lastly, we would to thank the Director General of Ministry of Health
Malaysia for his effort and support.

REFERENCES

Tan Sri Dato’ Seri Dr Noor Hisham bin Abdullah (13 January 2021). Surat Pekeliling Ketua

Pengarah Kesihatan Malaysia 2/2021. Pengurusan Kes Covid 19 dan Kontak Rapat

Semasa Pandemik Covid-19. 13

Tharanya Arumugam. (22 January 2021). 213 CAC Set Up Nationwide. News Straits Times.

Retrieved from https://www.nst.com.my/news/nation/2021/01/659794/213-covid-19-

assessment-centres-set-nationwide

Tuan Buqhairah Tuan Muhamad Adnan. (20 August 2021). 23,564 kes baharu, Malaysia

rekod kes harian tertinggi. Sinar Harian. Retrieved from

https://www.sinarharian.com.my/article/156683/KHAS/Covid-19/23564-kes-baharu-

Malaysia-rekod-kes-harian-tertinggi

Datuk Dr Chong Chee Keong (23 July 2021) Surat Pengaktifan Virtual CAC selaras

Perubahan Pengurusan Kes Covid 19 Yang Tidak Bergejala Dan Bergejala Ringan

Semasa Pandemik Covid 19 Bagi Greater Klang Valley.

Ong et al, Clinical and Virological Features of SARS-CoV-2 Variants of Concern: A

Retrospective Cohort Study Comparing B.1.1.7 (Alpha), B.1.315 (Beta), and

B.1.617.2 (Delta) 23 August 2021, Clinical Infectious Disease.

Laporan Mesyuarat Bilik Gerakan/CPRC Negeri Kedah 1 Ogos 2021 dan 17 Ogos 2021

Noorazura Abdul Rahman. (Julai 23, 2021). Katil hospital kerajaan di Kedah hampir penuh..

Berita Harian Online. Retrieved from

https://www.bharian.com.my/berita/wilayah/2021/07/842440/katil-hospital-kerajaan-

di-kedah-hampir-penuh

Dr Farique Rizal Bin Abdul Hamid (26 July 2021) Surat Carta Alir Rujukan dan Kriteria

Kemasukan Pesakit Covid-19 di PKRC dan Hospital di Negeri Kedah

78

CORONAVIRUS DISEASE (COVID-19) CLUSTER AMONG
MIGRANT WORKERS AT A LOCAL FACTORY IN KEDAH STATE

OF MALAYSIA IN 2021

Zul Azrizal Salleh1, Mohd Fairuz Addnan1*, Hanisah Ahmad1, Ahmad Hanis
Ahmad Shushami1, Shareh Azizan Shareh Ali1

1Kota Setar Health District Office.

*Corresponding author: Mohd Fairuz Addnan, Kota Setar Health District Office, Alor Setar, Kedah
[email protected]

ABSTRACT
Background: The migrant population acts as the epicentre of the epidemic in
several nations that absorb millions of foreign workers. In June 2021, one cluster of
COVID-19 has been reported among migrant workers in a local factory in Kedah
state of Malaysia. This paper aimed to describe the characteristics of COVID-19
cases and to outline the experience of COVID-19 outbreak containment in the
factory.

Methodology: A cross-sectional descriptive study was conducted by interviewing
the cases, factory workers and management staff and environmental investigation.
A confirmed COVID-19 case was defined as a worker in a factory ‘B’ between 2nd of
June until 26th of July with positive RT-PCR.

Results: A total of 229 confirmed cases were detected out of 1087 workers screened
in this cluster with overall attack rate of 21.1%. All of the cases were migrant workers
with the majority were originated from Bangladesh and Nepal. Environmental
investigation revealed that overcrowding in the dormitories lead to the outbreak.

Conclusion: The risk of SARS-CoV-2 transmission is higher among migrant
workers due to poor working and living conditions. The employer should strictly
comply to the regulations for workers accommodations and standard operating
procedure regarding prevention of COVID-19 in the workplace.

Keyword: COVID-19, Cluster, Migrant workers, Kedah, Malaysia

79

INTRODUCTION
On March 11, 2020, WHO had declared the coronavirus disease 2019 (COVID-19)
as a pandemic (WHO, 2020). As of 24 January 2022, there were 349,641,119
confirmed cases of COVID-19 with 5,592,266 confirmed deaths (WHO, 2021). High
density workplaces have been linked to high risk transmission of severe acute
respiratory disease coronavirus 2 (SARS-CoV-2) in the recent year. The migrant
population acts as the epicentre of the epidemic in several nations that absorb
millions of foreign workers. In Singapore, for example, as of the end of May 2020,
the great majority of 30,000 infected people were migrant labourers living mostly in
employer-sponsored dorms (Koh, 2020; Wahab, 2020).

The first case of COVID-19 in the factory ‘B’ was identified from a migrant worker
who developed fever and cough and confirmed positive of COVID-19 on 2nd of June
2021. Factory ‘B’ is situated in Pokok Sena district in Kedah state and consists of
1376 workers which 1087 individuals were migrant workers. The employer provides
accommodation to all their migrant workers. For their accommodation, the
dormitories were divided into two building which was Hostel 1, that accommodates
366 workers and Hostel 2 that accommodates 721 workers. This cluster infected a
total of 229 workers from the reporting period of 3rd of June 2021 until 26th of July
2021. The locality was placed under the Enhanced Movement Control Order
(EMCO) from 26th of June 2021 until 23rd of July 2021 (The Star, 2021).

In view of COVID-19 as a newly emerging disease, sharing of knowledge and
successful experience in outbreak management especially among factory migrant
workers is particularly important to give implications and reference to other
stakeholders in future management of similar condition. This paper aimed to
describe the characteristics of COVID-19 cases and to outline the experience of
COVID-19 outbreak containment in a local factory in Pokok Sena district, Kedah
state of Malaysia.

METHODOLOGY
This is a descriptive cross-sectional study. Data collections consisted of in-depth
interviews with the cases, factory workers and management, reviewing medical
records and environmental survey at the factory.

Contact tracing were conducted using “COVID-19 Management Guidelines in
Malaysia No.5/2020” by the Ministry of Health (MoH Malaysia, 2021). We defined a
confirmed case as a worker of Factory ‘B’ that showed positive test for SARS-CoV-
2 by RT-PCR during period of 2nd of June 2021 to 26th of July 2021. A cluster is
defined as two or more cases of similar infectious disease happened in close

80

No. of casesproximity or had epidemiological link to each other and happened within the same
incubation period. A close contact was defined as any person interacting with a
confirmed case of COVID-19 within a one-meter distance for at least five minutes,
or being coughed or sneezed on, or being in an enclosed space without proper
ventilation with a confirmed case for at least 15 minutes.

Environmental investigation were performed by field examination and risk
assessment of the factory and dormitories. The assessment was also done based
on Employees’ Minimum Standards Of Housing, Accommodations And Amenities
Act 1990. Data entry and analysis were done using Microsoft Excel. Descriptive
statistics with mean and standard deviation (SD), frequency and percentages were
calculated.

RESULTS
From 3rd of June 2021 until 26th July 2021, a total of 229 confirmed cases were
detected out of 1087 workers screened in this cluster with overall attack rate of
21.1%. Figure 1 depicts the distribution of the cases based on date of reporting. The
index case was a 23-year-old Bangladeshi male who developed fever one week prior
to PCR test.

80
70
60
50
40
30
20
10

0

Date of reporting

Figure 1: Epidemic curve of COVID-19 Cluster in Factory ‘B

Characteristics of the cases
The characteristics of the confirmed cases are displayed in Table 1. The mean age
was 32.8 years (SD 5.57). Almost all of the cases were male except for two cases
of female workers. All of the cases were migrant workers with the majority were
originated from Bangladesh and Nepal.

81
28-May
29-May
30-May
31-May

1-Jun
2-Jun
3-Jun
4-Jun
5-Jun
6-Jun
7-Jun
8-Jun
9-Jun
10-Jun
11-Jun
12-Jun
13-Jun
14-Jun
15-Jun
16-Jun
17-Jun
18-Jun
19-Jun
20-Jun
21-Jun
22-Jun
23-Jun
24-Jun
25-Jun
26-Jun
27-Jun
28-Jun
29-Jun
30-Jun
1-Jul
2-Jul
3-Jul
4-Jul
5-Jul
6-Jul
7-Jul
8-Jul
9-Jul
10-Jul
11-Jul
12-Jul
13-Jul
14-Jul
15-Jul
16-Jul
17-Jul
18-Jul
19-Jul
20-Jul
21-Jul
22-Jul
23-Jul
24-Jul
25-Jul
26-Jul
27-Jul
28-Jul
29-Jul
30-Jul
31-Jul

Table 1: Characteristics of confirmed cases

Characteristics n % Mean SD
32.80 5.57
Age (years) - -
- -
Gender 227 99.1 - -
Male 2 0.9
Female - -
152 66.4 - -
Nationality 1 0.4 - -
Bangladesh 10 4.4 - -
Cambodia 12 5.2 - -
Indonesia 47 20.5 - -
Myanmar 1 0.4 - -
Nepal 6 2.6 26.75 4.96
Pakistan -
Vietnam -

CT Value

Environmental investigation
Field Investigation was performed in both the factory’s workplace and their
residential areas. It was found that there were movement between rooms and
movement of going outside of the factory to nearby shops without wearing face
mask. Table 2 summarizes number of rooms and workers based on different block
during field investigation. Assessments of dormitories of the workers revealed that
the room was overcrowded as it accommodates between eight to twelve person and
the ratio of the toilet to the workers did not meet the requirement of Employees’
Minimum Standards Of Housing, Accommodations And Amenities Act 1990

Table 2: Summary of hostel occupancy

Block Number of Number of Workers Average Workers
Per Room
Rooms Identified 7
9
1 12 79 8
8
2 12 110 7
8
3 12 94 4
8
4 12 100 11
7
5 12 85

6 12 101

7 28 108

8 20 155

9 20 210

TOTAL 140 1042

82

Contact tracing
Active case detection (ACD) was performed by identifying workplace contacts and
social contacts who fulfil close contact criteria through case investigation and field
investigation. Initially, close contacts were identifeide based on shared rooms and
staying in the same block. Subsequently, as the number of cases keep on rising, all
workers had been screened.

Control measures
A total of 229 workers had been detected as confirmed case from the reporting
period of 3rd of June 2021 until 26th of July 2021. The locality was placed under the
Enhanced Movement Control Order (EMCO) from 26th of June 2021 until 23rd of
July 2021. All positive cases had been referred to isolation centre. All close contacts,
had been quarantined in separate area in the factory for 14 days and subjected for
second sample between day 10 to 13.
Health education were also given to the management and workers regarding
COVID-19 signs and symptoms, mode of transmissions, management of positive
cases and the importance of abiding to home quarantine order.

DISCUSSIONS
All of the confirmed cases in this cluster were migrant workers who lived in crowded
dormitories which lead to higher risk of SARS-CoV-2 transmission. In spite of
existing act and regulations, conditions in the dormitories still allowed the COVID-19
outbreak to emerge. This is most likely due to the difficulties in practising proper
physical distance, mixing of inhabitants in common areas and shared facilities, such
as toilet, cooking, dining and recreational activities. Migrant workers in Malaysia are
already living in overcrowded situations and unwarranted accommodation, lack of
proper water supply and electricity and basic sanitation (Wahab, 2020).

Case investigation and contact tracing, a core disease control measure employed
by local and state health department personnel for decades, is a key strategy for
preventing further spread of COVID-19 (CDC, 2020). However in this cluster during
initial period of invstigation, language barrier among the mgrant workers lead to
difficulty in contact tracing. To overcome this, we identified close contacts by
obtaining the contacts in the dormitories based on the location of the rooms and
nationality. As the number of cases keep on increasing and further risk assessment
suggested that the larger magnitude of the outbreak, we decided to screened all the
migrant workers. Due to such drastic measure and with the enforcement of total
lockdown, we were able to control the outbreak in a timely manner.

83

There are some limitations that need to be acknowledged in this study. Data on
clinical history and comorbidities of the cases were not explored as it was not
recorded at the district health office level. Moreover, laboratory findings for all
confirmed cases were not studied and described as these data were recorded
separately in cases’ respective quarantine centre and were not shared in online
registry.

CONCLUSION
This COVID-19 cluster has highlighted migrant workers as a vulnerable occupational
group. The risk of SARS-CoV-2 transmission is higher among this group of workers
due to poor working and living conditions. Ideally, issues related to migrant workers
(and other similarly affected populations) such as inadequate and overcrowded
accommodations need to be addressed before a pandemic. The employer should
strictly comply to the regulations for workers accommodations and standard
operating procedure regarding prevention of COVID-19 in the workplace. Otherwise,
these areas might become COVID-19 epicentres, leading to more widespread local
transmission in the general community.

ACKNOWLEDGEMENT
The authors would like to thank the Director General of Health Malaysia for his
permission to publish this article. We would also like to thank the all health
inspectors, medical officers and staff of Kota Setar District Health Office, Kedah
State Health Department and other agencies in contributing to the success of
COVID-19 management in Kota Setar district.

REFERENCES

CDC. (2020). Case Investigation and Contact Tracing: Part of a Multipronged Approach to
Fight the COVID-19 Pandemic. Retrieved January 2, 2022, from
https://www.cdc.gov/coronavirus/2019-ncov/downloads/php/principles-contact-tracing-
booklet.pdf

Koh, D. (2020). Migrant workers and COVID-19. Occupational and Environmental Medicine,
77(9), 634–636. https://doi.org/10.1136/oemed-2020-106626

MoH Malaysia. (2021). COVID-19 Management Guidelines in Malaysia No.5 / 2020. Retrieved
January 1, 2022, from https://covid-19.moh.gov.my/garis-panduan/garis-panduan-kkm

The Star. (2021). Ismail Sabri: Several areas in Kedah, Sabah under EMCO from June 26-July
9. Retrieved from https://www.thestar.com.my/news/nation/2021/06/24/ismail-sabri-
several-areas-in-kedah-sabah-under-emco-from-june-26-july-9

Wahab, A. (2020). The outbreak of Covid-19 in Malaysia: Pushing migrant workers at the
margin. Social Sciences & Humanities Open, 2(1), 100073.

WHO. (2020). WHO Director-General’s opening remarks at the media briefing on COVID-19 -
11 March 2020. Retrieved January 1, 2022, from https://www.who.int/director-
general/speeches/detail/who-director-general-s-opening-remarks-at-the-media-briefing-
on-covid-19---11-march-2020

WHO. (2021). Weekly Operational Update on COVID-19. World Health Organization (WHO),
(53), 1–10.

84

CHALLENGES IN DAH KUALA JERLUN COVID-19 CLUSTER
CONTAINMENT: HIGHLIGHTING PUBLIC HEALTH APPROACH

TACKLING PERSONS WHO INJECT DRUGS

Ku Saifullah KI1, Ikhwan MI¹, Mohd Faiz I2, Mohamad Affiz MY3, Zukri MI3

1Department of Community Medicine, School of Medical Sciences, Universiti Sains Malaysia
2Department of Community Health, Faculty of Medicine, University Putra Malaysia
3Kubang Pasu District Health Office
*Corresponding author: Ku Mohd Saifullah Ku Ismail, MD, MPH, Department of Community
Medicine, School of Medical Sciences, Universiti Sains Malaysia. Email: [email protected]

ABSTRACT

Background: Effective COVID-19 cluster containment requires a good cluster management
strategy, adherence to the standard of procedures (SOP) among the communities, and inter-
sectoral coordination. Persons who inject drugs (PWID) may not adhere to SOP related to
COVID-19 and hinder control measure activities to curb disease transmission during cluster
containment. This study aimed to describe the challenges and actions taken by Kubang
Pasu District Health Office (PKD Kubang Pasu) to tackle PWID issue to contain Dah Kuala
Jerlun COVID-19 cluster.

Methodology: Any COVID-19 cases that had epidemiological link with Dah Kuala Jerlun
COVID-19 from 17th July 2021 until 28th August 2021 were recruited into the study. Socio-
demographic of COVID-19 cases and PWID with confirmed COVID-19 involved in this
cluster were described in frequency (percentage) for categorical factor and mean (standard
deviation) for numerical factor, and the strategies implemented by PKD Kubang Pasu and
its challenges to tackle PWID group during cluster containment were summarized.

Results: There were a total of 331 COVID-19 cases registered in this cluster, with 31 PWID
identified during the cluster containment period. Majority of the case were aged less and
equal ten years old (71, 21.45%), male (177, 53.47%), Malay (331, 100.00%), unemployed
(114, 34.44%). Eleven (3.32%) death related to COVID-19 were reported in this cluster.
Activities related to PWID and public gatherings during Eid Hajj were identified as factors of
disease transmission in the community. Besides the fundamental COVID-19 response to
contain this cluster, special quarantine building for PWID and multi-agencies collaboration
and coordination were highlighted.

Conclusion: The PWID group needs to be tackled as fast as possible during cluster
containment measures, preventing further potential cases and minimizing severe outcomes.
Collaboration with multiple agencies during case investigation and contact tracing in the
cluster with the PWID group may attribute to effective control measures.

Keyword: COVID-19, Dah Kuala Jerlun, PWID, PKD Kubang Pasu.

85

INTRODUCTION

The Coronavirus Disease 2019 (COVID-19) pandemic has been the leading public
health focus since late 2019. Current control measures in Malaysia, such as
movement control order towards COVID-19 pandemic give huge impacts on
healthcare, social capital, economic and tourism sectors (Cheng, 2020; Karim et al.,
2020; Menhat et al., 2021; Shah et al., 2020; Yong et al., 2021). However, non-
adherence to COVID-19’s SOP among the community leads to ineffective and
inefficient public health efforts toward COVID-19 disease containment (Che Ghazali
et al., 2021; Rampal et al., 2020). Dah Kuala Jerlun COVID-19 cluster also had a
similar issue, with the period of disease control measures being extended most
probably due to non-adherence with SOP among persons who inject drugs (PWID).
The issue involving PWID behaviour during COVID-19 transmission in Kubang Pasu
was underreported before, thus knowing their risk behaviour that contributed to
COVID-19 transmission or other communicable diseases may benefactive in
designing the intervention in the future.

In addition to non-adherence with SOP issues, PWID is also a known group with a
higher risk of COVID-19 infection (Benzano et al., 2021) and is more likely to develop
severe COVID-19 infection (Iversen et al., 2021; Jacka et al., 2020; Vasylyeva et al.,
2020). Their risk factors such as weakened immune system, drug misuse, smoking,
reduced access to health care services, and syringe exchange program during
COVID-19 pandemic may exacerbate their health (Abadie et al., 2021). The SOP
during pandemic highlighting social distancing and staying home as much as
possible leads to increased boredom and change their routines prone to COVID-19
transmission (Celentano et al., 2001). Moreover, loss of income during pandemic
has raised several issues such as isolation-related illness, assessing drugs, and less
connection with peers. Their perception and behavior also pose several problems,
including misinformation on COVID-19 infection, less concern about contracting
COVID-19 infection, and more likely not comply with a quarantine order. They also
generally experienced similar symptoms of COVID-19 infection with symptoms of
substance addiction, rendering them neglecting to seek early treatment (Agramunt
and Lenton, 2021; Kesten et al., 2021).

Consequences of their attitude and perception during COVID-19 cluster containment
include increased COVID-19 transmission in the community due to non-compliance
to SOP and increased morbidity and mortality rate among PWID and their
surrounding community, making the outbreak hardly possible to be contained
(Vasylyeva et al., 2020). However, limited literature has described the method to
tackle this group during COVID-19 cluster containment efficiently. Hence, this study
will describe the COVID-19 cases and PWID involved in this cluster and the

86

challenges and actions taken by Kubang Pasu District Health Office (PKD Kubang
Pasu) to tackle the PWID issue to contain Dah Kuala Jerlun COVID-19 cluster.

METHODOLOGY

Cluster setting and background
Dah Kuala Jerlun COVID-19 cluster was declared on 21st July 2021, located in Jerlun
sub-district, under Kubang Pasu District, Kedah. The cluster involved 11 localities
that were estimated at around 3100 population. The primary issues with these
localities were congested fishing villages with crowded houses. They shared a
similar environment and socio-economic activities, mostly centered at fisherman’s
market at Kuala Jerlun’s jetty, which favored the rapid spread of communicable
diseases. Moreover, these localities were known for high incidence rates of
tuberculosis and HIV/AIDS, with substance abuse being highlighted as the leading
social issue. Kuala Jerlun’s jetty was the hotspot for drug trafficking in this sub-
district. Based on risk assessment, case investigation, and informal information from
other agencies, non-adherence to SOP among the community was low before the
establishment of the cluster. The cause of the cluster was activities related to PWID
and visiting activities within the community during Eid Hajj.

Epidemiological investigation and control measures
The index case was Mr. A, 51 years old, a surveyor, who went from Penang to
Kampung Baru Jeruju to accompany his father-in-law for a vaccine jab at the
vaccination center. He was asymptomatic; however, he was tested for COVID-19
Antigen Rapid Test Kits (RTK-Ag) as closed contact when his father-in-law was
positive for COVID-19 on 15th July 2021, which revealed negative. So he repeated
the PCR test and revealed positive on 18th July 2021.

Contact tracing is carried out within 24 hours once the COVID-19 case was
confirmed by PCR test, and the criteria for close contact were defined according to
the guideline provided by the Ministry of Health (MOH) (MOH, 2021). For
symptomatic cases, PCR tests were performed on all close contacts who had been
significantly exposed to the case within two days of the onset date. For asymptomatic
cases, PCR tests were performed on all their close contacts who had been
considerably exposed to the cases within two days of the swab date. Once the
cluster was declared, all symptomatic persons with upper respiratory tract infection
were subjected to PCR screening. Case investigation and contact tracing were
carried out with the Department of Community College Education (JPKK) assistant,
representative of the fishermen's association, and traders from Kuala Jerlun.
Home self-isolation (HSO) was ordered once they were classified as close contact,
and their daily symptom was monitored until completed 14 days of isolation.

87

Targeted screening in the field was indicated for the Individuals or close contact with
symptom and co-morbidity, fisherman and fishmonger at the fisherman's market,
and high-risk individuals for COVID-19 infection. Risk assessments were conducted
on all cases, and cases were referred to the COVID-19 assessment center (CAC)
Kubang Pasu or designated hospital for COVID-19 if indicated.
Health education activities were conducted using CAPP (Prevent, Charity, Obey,
Monitor) approach with the collaboration of Kubang Pasu District Office, JPKK, and
State Assemblyman. Disease control and HSO compliance monitoring were carried
out with JPKK and police. Closure of the fisherman's market at Kuala Jerlun's jetty
was used as part of the enforcement effort to prevent disease transmission in the
public area. Disinfection activities were done to public premises, assisted by
volunteers, ADUN service center, and volunteer fire brigade from Ayer Hitam.
Outreach COVID-19 vaccination programs were deployed in several localities during
the cluster period.

Statistical method
Socio-demographic characteristics of COVID-19 cases and PWID with confirmed
COVID-19 involved in Dah Kuala Jerlun cluster were described in frequency
(percentage) for categorical factor and mean (standard deviation) for numerical
factor. The epidemic curve was constructed based on the date of positive COVID-
19 via PCR. To visualize the distribution of the cases, the bubble map was generated
using ‘tmap’ and ‘leaflet’ packages within Rstudio version 1.4.1717 (RStudio Team,
2020).

RESULTS

There were total of 331 COVID-19 cases involving Dah Kuala Jerlun cluster, and
their socio-demographic characteristics were shown in Table 1. The mean of age
was 30.58 years old, and age equal to or less than ten years was most cases. All
cases were Malay, and cases among males were more dominant in the cluster than
women. Majority of the cases were unemployed. The mean for cycle threshold (CT)
value among cases was 25.00.

The localities involved in this cluster were described in the Figure 1. There was a
total of 11 localities involved in this cluster, with locality Kampung Kuala Jerlun
having the highest number of cases (138 cases), followed by locality Kampung Baru
Jeruju (82 cases) and locality Kampung Desa Murni (32 cases). All localities located
within Jerlun sub-district, with had good access by road to Kota Setar district at the
south, and by sea route to other fishing village such as Kuala Perlis, Kuala Kedah
and Langkawi.

88

Table 1: Socio-demographic characteristic of COVID-19 cases in Dah Kuala Jerlun

cluster, n=331.

Variables Mean (SD) n (%)

Age group 30.58 (21.00)
≤10 years old
71 (21.45)

11-20 years old 65 (19.64)

21-30 years old 43 (12.99)

31-40 years old 52 (15.71)

41-50 years old 32 (9.67)

51-60 years old 28 (8.46)

>60 years old 40 (12.08)

Sex

Male 177 (53.47)

Female 154 (46.53)

Ethnicity

Malay 331 (100.00)

Occupation 114 (34.44)
83 (25.08)
Unemployed 30 (9.06)
5 (1.51)
Student 5 (1.51)
5 (1.51)
Fisherman/Fishmonger 3 (0.91)
12 (3.63)
Factory Worker 74 (22.36)

Odds Job 320 (96.68)
11 (3.32)
Trader

Rice Farmer

Others

Unknown

CT Value From PCR* (RDRP)) 25.00 (6.42)

Outcome

Alive

Death

* Cycle threshold value from polymerase chain reaction

Figure 1: Distribution of COVID-19 cases in Dah Kuala Jerlun cluster based on

locality. The number in th parenthesis represents number of COVID-19 cases.
89

Number Of CasesThe epidemic curve depicted in Figure 2 demonstrated a propagated pattern that
occurred with multiple peaks. The cluster began on 17th July 2021 and was declared
on 21st July 2021. Even though the cluster was relatively declared quite early for
disease control measures, however, COVID-19 transmission propagated several
times later until the cluster was under control after more than a month of disease
containment efforts.
There was a total of 31 cases among active PWID were detected during contact
tracing activities, and their socio-demographic characteristic and CT value were
shown in Table 2. Majority of them were aged between 31 to 40 years old (9, 29.03%),
male (30, 96.77%), and lived in Jerlun according to their address (25, 80.65%). All of
them were isolated at Institut Aminuddin Baki (IAB).

70
COVID-19 cluster

declared on 21st July
60 2021
50

40

30

20

10

0

Date Of Positive COVID-19

Figure 2: Epid curve for COVID-19 cases in Dah Kuala Jerlun cluster by date of
positive COVID-19.

90
01-Jul
03-Jul
05-Jul
07-Jul
09-Jul
11-Jul
13-Jul
15-Jul
17-Jul
19-Jul
21-Jul
23-Jul
25-Jul
27-Jul
29-Jul
31-Jul
02-Aug
04-Aug
06-Aug
08-Aug
10-Aug
12-Aug
14-Aug
16-Aug
18-Aug
20-Aug
22-Aug
24-Aug
26-Aug
28-Aug
30-Aug

Table 2: Socio-demographic factors of COVID-19 cases among PWID isolated at

IAB, n=31.

Variables Mean (SD) n (%)

Age 32.26 (10.07)

11-20 years old 6 (19.35)

21-30 years old 8 (25.81)

31-40 years old 9 (29.03)

41-50 years old 7 (22.58)

51-60 years old 1 (3.23)

Sex

Male 30 (96.77)

Female 1 (3.23)

Nationality

Malaysia 31 (100.00)

Address by Sub-district

Jerlun 25 (80.65)

Jitra 1 (3.23)

Others 5 (16.13)

CT Value From PCR* 28.51 (5.34)

(RDRP)

* Cycle threshold value from polymerase chain reaction

DISCUSSION

Poor attitude and behavior among PWID towards COVID-19 disease render cluster
containment more challenging. High mean CT value from Table 2 (28.51) among
PWID compared to CT value from the community (25.00) in Table 1 may represent
late case detection among PWID and were in the infective period, rendering high
transmission of COVID-19 to their surrounding communities (La Scola et al., 2020;
Rabaan et al., 2021). Implementation of HSO among PWID in their own house or
quarantine center may aggravate COVID-19 transmission in the community and
other populations (Vasylyeva et al., 2020).

Meanwhile, incarceration may help to improve COVID-19 testing among PWID as
described by Yeager et al. (2022); however, Vasylyeva et al. (2020) has highlighted
that incarceration may lead to uncontrolled COVID-19 transmission due to crowded
population, poor ventilation within facilities, and poor access to soap and water in
the jail and prison. Isolation of cases among PWID at their own house were
unsuitable as their environment was favorable for COVID-19 transmission.
Resettlement areas in the fishing village were cramped with small house, and most
of the houses accommodated high number of family members; therefore, the
presence of PWID may provide a higher risk of COVID-19 transmission among
family members. As a result, PWID with suspected and confirmed COVID-19

91

infection was quarantined in IAB, a special quarantine zone that uses buildings from
the Ministry of Education’s facility, avoiding them from home quarantine and isolating
them from other communities in PKRC.

Case investigation among PWID also posed COVID-19 management issue, where
unreliable history taking, inadequate staffing to interview and sampling them in the
field, as well as PWID individuals without telecommunication devices had limiting
contact tracing activities in the cluster area and reduced effectiveness of cluster
containment activities. Furthermore, health staff found it was difficult to interview and
sample them since they refused to stay at home throughout the day during the
cluster period to meet with their peer group. The implementation of an enhanced
movement control order was less successful due to the nature of the housing area
and the geographical location, both of which are unsuited to restrict PWID’s
movement.

This group tends to flee from authority through sea route and the hidden land route
to meet their peer group in other location, which lead to sub-cluster in other district
and state. The police were deployed to all entrances and exits to the clustering area
to minimize their movement. The Marine Police Force has monitored all boats that
are coming in and out from Kuala Jerlun’s jetty, allowing only essential activities and
services to be functioning and limiting PWID’s movement on the sea at the same
time. Fisheries Development Authority of Malaysia (LKIM) had provided list of all
fisherman registered in Kuala Jerlun to PKD Kubang Pasu for screening activities.
Inspectorates have conducted large-scale enforcement activities and collaborated
with National Anti-Drugs Agency (AADK) to recognize PWID in the population. AADK
had identified PWID among suspected and confirmed COVID-19 cases through the
interview and checklist, and all active PWID with positive urine drugs were
transferred to IAB for quarantine. They were required to complete their isolation
period according to MOH’s guideline, and further action by police was taken after
they were discharged from IAB.

Limitation
The actual number of cases among PWID in this cluster may be underreported as
several PWID with possibly contracted with COVID-19 infection were not detected
or escaped during contact tracing activities within the period of containment. Some
useful socio-demographic characteristics to describe susceptibility and severity of
illness towards COVID-19 infection, such as level of education and co-morbidity,
were not described in this study due to limited access to data collection during
contact tracing and the nature of the community.

92

CONCLUSION
PWID group need to be tackled as fast as possible during cluster containment
measures, which may prevent further potential cases and minimize severe
outcomes. Even though any targeted approach for PWID to contain COVID-19
infection during COVID-19 outbreak seem difficult to be implemented due to their
behaviour and precautions for COVID-19 infection, but collaboration with multiple
agencies during case investigation and contact tracing in the cluster with PWID
group may attribute to effective control measures during the outbreak.

ACKNOWLEDGEMENT

The authors would like to thank the Director General of Health Malaysia for his
permission to publish this article. We also like to express our gratitude to all health
personnel, who are helping us with data collection and sharing experiences.

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94

COVID-19 MORTALITY CASES IN KUBANG PASU DISTRICT: A
DESCRIPTIVE STUDY

Mohd Faiz I1, Zukri MI.2, Ku Saifullah3, Ikhwan MI.3,
Mohamad Affiz Y2

1Department of Community Health, Faculty of Medicine and Health Sciences, Universiti Putra
Malaysia.
2Kubang Pasu Health District Office.
3Department of Community Health, Faculty of Medicine and Health Sciences, Universiti Sains
Malaysia.
*Corresponding author: Mohd Faiz Bin Itam, [email protected]

ABSTRACT

Background: COVID-19 has rapidly impacted on mortality worldwide. Early
identification of COVID-19 cases in community at high risk of death can enhance
patient treatment and resource allocation. The goal of this study is to identify the
characteristics of COVID-19 mortality cases in Kubang Pasu districts in 2021.
Methodology: A cross sectional study was done on 210 COVID-19 mortality cases
in 2021 in Kubang Pasu district. Data on mortality cases were analysed descriptively
using Microsoft Excel.
Results: There are 210 (1.9%) mortality cases had been recorded in 2021 due to
Covid-19 infection form 11019 Covid-19 cases in Kubang Pasu district. The mortality
cases consist of 108 (51%) female and 102 (49%) males. The highest mortality
cases involved the age group of more than 70 years old, with 73 (34.8%) cases. The
highest race was Malay 193 (91.9%), followed by non-Malaysian 6(2.9%), Chinese
4(1.9%), Siamese 4(1.9%) and Indian 3(1.4%) respectively. Most of the mortality
cases are unvaccinated 153 (72.9%). The most common cause of death is due to
Covid-19 pneumonia with 205 (97.5%) cases. Majority of the cases were screen
through symptomatic screening and close contact screening 86 (40.9%) cases and
52 (24.8%) respectively. Among the mortality cases, there are 22(10.5%) brought-
in-death cases which 19 (86%) cases are Malay. Most of the brought-in-death cases
are unvaccinated, 19 (86%) cases, incomplete vaccine 1 (5%) case and 2 (9%)
cases completed vaccine.
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.
Those who are more than 70 years old were those with multiple co-morbidities and
tend to get severe Covid-19 symptoms. Despite proven effectiveness of vaccine
against severe symptoms and reduce mortality, there are still many of the mortality
case who are eligible for vaccine were not vaccinated Promotion activities about
Covid-19 and vaccine should be strengthened further to improve the knowledge and
actions towards Covid-19 in community.

Keyword: Covid-19 mortality, brought-in-dead, Covid-19 pneumonia, Covid-19
vaccine, health-seeking behaviour.

95

INTRODUCTION

The continuing coronavirus disease pandemic (COVID-19) caused by severe acute
respiratory syndrome coronavirus 2 (SARS-CoV-2) has resulted in an alarming
number of deaths worldwide (Dong et. al., 2020). Scenarios of COVID-19 mortality
have been critical inputs for pandemic response efforts, and decision-makers
needed information about pandemic control activities performance (Friedman et. al.,
2021). Until December 2021, there are 290 million cumulative cases recorded
around the world with almost 2.8 million cumulative cases in Malaysia (Hirschmann,
2022). Much is unclear about the disease dynamics and risk factors as the pandemic
spreads over the world. A greater knowledge of the clinical drivers of illness severity
can help to enhance patient care across the healthcare system. This work is difficult
due to the disease's fast spread and a lack of precise patient data. The number of
mortalities in each nation, as well as the trajectory of each country's mortality rate,
are indicators of great public interest that are regularly debated by public health
specialists.

In 2021, there were 11019 cases of Covid-19 recorded in Kubang Pasu district with
210 mortality cases. Data of the mortality cases had been collected through the
surveillance system at the district level and had been analyzed to describe the
characteristics of the cases descriptively. It is important to know the characteristics
of the mortality cases in Kubang Pasu so that we can plan proper intervention plan
to reduce the number of the mortality cases.

METHODOLOGY

Study design: A cross sectional study was done to n = 210 of mortality cases in
Kubang Pasu district. Period under study is from January to December 2021, using
data of confirmed mortality cases due to Covid-19 for surveillance data of 11, 019
Covid-19 cases in Kubang Pasu District in the year 2021. The listing of mortality
cases due to Covid-19 in Kubang Pasu District in 2021 had been analysed
descriptively.

Case definition: The diagnosis of Covid-19 cases was confirmed by RT-PCR and
RTK test done to the patient/deceased as per guideline by the Ministry of Health
Malaysia (Ministry of Health Malaysia, 2021).

Completed doses of vaccines refer to the 14 days after the recommended doses of
vaccine (CoronaVac-Sinovac, Comirnaty-Pfizer BioNTech® and Oxford-
AstraZeneca) (Oliver et al., 2020 and Centers for Disease Control and Prevention,

96

2021). For all vaccine types, we defined individuals to be fully vaccinated 14 days
after the final dose. We considered individuals who received only the first dose or
died within 14 days after the final dose as partially/incomplete vaccinated.

Data analysis/data managemen
Data were extracted and analyzed with descriptive statistics of variables given by
arithmetic mean and standard error of the mean using Microsoft Excel. The
incomplete data were deal by calling back the patient family members and counter
checking from vaccine record and Covid-19 investigation form.

RESULTS

A total of 210 COVID-19 deaths were reported during 2021, from January to
December 2021. The trend of COVID-19 death cases showed an increase in parallel
with the number of new case detections as shown in figure 1.

3500 80

3000 70
2500 60
2000 50
1500 40
1000 30
20
500 10

0 Marc 0
h
Jan Feb April May June July Aug Sept Oct Nov Dis

Community cases 108 12 8 44 1373 372 557 2989 2669 826 1171 890

Mortality case 1 0 0 4 30 6 28 75 43 5 14 4

Mortality percentage 0.9 0.0 0.0 9.1 2.2 1.6 5.0 2.5 1.6 0.6 1.2 0.4

Community cases Mortality case Mortality percentage

Figure 1: Monthly mortality versus Covid-19 cases in community.

As refelected in the figure 1, the highest mortality cases was in August 2021 with 75
(35.7%) cases from the total 210 mortality cases. No mortality cases recorded in
February and March.

97

Sociodemographic characteristics
From the data collected, 210 (1.9%) mortality recorded in 2021 due to Covid-19
infection form 11019 Covid-19 cases in Kubang Pasu district, the mortality cases
consist of 108(51%) females and 102(49%) males. The highest cases by race were
Malay 193(91.9%), followed by non-Malaysian 6(2.9%), Chinese 4(1.9%), Siamese
4(1.9%) and Indian 3(1.4%), respectively.

Table 1: Sociodemographic of mortality cases

Variables n (%) Mean (SD)
62.2(±15.1)
Gender

Male 102 (48.6)

Female 108 (51.4)

Race

Malay 193 (91.9)

Chinese 4 (1.9)

Indian 3 (1.4)

Siamese 4 (1.9)

Non-Malaysian 6 (2.9)

Group age

<30 7 (3.3)

31-40 16 (7.6)

41-50 17 (8.1)

51-60 46 (21.9)

61-70 51 (24.3)

>70 73 (34.8)

The mortality rate of COVID-19 cases was found to increase with age. In general,
the mean age for COVID-19 deaths in the year 2021 was 62.2 (± 15.13) years. Those
over 70 years old were found to have the highest mortality cases of 73 (34.8%)
cases, followed by aged 61-70 years with 51 (24.3%) cases and 46 (23%) cases for
those aged 51-60 years.

98

BINJAL 5 10 15 20 25 30 35
PADANG PERAHU

WANG TEPUS
PELUBANG
MALAU
GELONG

KUBANG PASU
PUTAT
HOSBA

BUKIT TINGGI
PERING

TUNJANG
SANGLANG

SG LAKA
AH

TEMIN
KEPLU
JERAM
JITRA
NAGA
JERLUN

0

Figure 2: Mortality cases according to sub-district.

The highest number of mortality cases was recorded in the subdistrict of Jerlun and
Naga with 33 cases each. It covers 31.4% (66 cases) from the total mortality cases
in Kubang Pasu district.

Vaccination status

Table 2 shows the vaccination status of the mortality cases. From 210 mortality
cases, there are 153 (72.9%) cases are unvaccinated, most of the unvaccinated
cases came from the age group of more than 70 counted at 53 (34.6%) cases.
Majority of them are Malay race 138 (90.2%) cases followed by non-Malaysian,
Chinese, Indian and Siamese, 5 (3.3%) cases, 4 (2.5%), 3 (2.0%) and 3 (2.0%)
respectively. In term of gender, shared almost the same number with 77 (50.3%)
cases are male and 76 (49.7%) cases female.

99