The Quadrivalent Covid-19 Clusters — Dr Musa Mohd Nordin

With the cry for personal protective equipment (PPE) from our health care workforce on the ground and the admission of the MOH on the depleting supplies of PPE, it is not too difficult to anticipate breakthrough Covid-19 infections among our health care workers.

The nation is finally beginning to see a favourable trajectory of the Covid-19 epidemic curve. Provided there are no unsuspected surges of positive cases, the trend suggest a genuine flattening of the epidemic curve unlike the premature pronouncements on the first and tenth of April.

I disputed the MOH (Ministry of Health) analysis on the plateauing of the curve on the 1st April, and instead suggested that the MCO (Movement Control Order) had favourably impacted on the curve trajectory by preventing an exponential surge of Covid-19 cases, instead demonstrating only a linear progression of cumulative cases.

A similar prognosis was made by the MOH on the 10th April 2020, prompting minister Azmin Ali to among others permit the opening of barbers to operate, which was later halted by the MOH saying “so postpone (allow some economic sector to operate) first, so that we can look back on our data.”

I listed six challenging circumstances which needed to be addressed convincingly prior to witnessing an authentic curve flattening and its sustainability.

Three was mentioned in my notes on the 11th April 2020 as a rebuttal to the proposition by the MOH, and the fourth which I have now added is an increasingly worrying trend.

As a side note, it is most unfortunate to mention that our lay public, and even our supposedly informed rakyat do not take kindly to opinions that runs counter to the official viewpoints, in this particular case that of the MOH. The Malay saying goes: “Jangan nak tunjuk pandai”.

Our colleagues in academia and research will testify that healthy skepticism is an invaluable quality in every scientist to evaluate the strengths and weaknesses of a hypothesis, the contending issue presently being the flattening of the Covid-19 curve.

One cannot run away from the unpalatable reality that the MOH maybe constrained by socio-economic pressures to please their political masters and to reassure the panic stricken rakyat.

This is unlike researchers, who are bent in the pursuit of the scientific truth and are only driven by data and are evidence-based. How one shares the “not so good new example, our curve is not quite bending yet” is the art of medicine.

Despite the paucity of big data locally, unlike the outpouring of detailed data sets from China and Singapore in the face of a similar crisis, we have been able to construct a plausible and alternative hypothesis.

This was made possible in consultation with major Covid-19 analytical players namely, the Malaysian Institute of Economic Research (MIER), Selangor Task Force on Covid-19 (STFC) and major references to both the John Hopkins Group and the Oxford Group.

My earlier list of three fears and concerns revolved around three clusters of Covid-19 outbreaks.

1. The Tabligh Cluster

The Ijtima’ Tabligh in Seri Petaling Mosque, from 28 Feb-1 March 2020, was the epicenter of the second wave of Covid-19 in our country. In fact, it has become South East Asia’s Covid-19 hotspot.

The Tabligh cluster contributed 14/61 (23%) of deaths in our earlier case series description of the first 61 deaths.

One can only suggest that the Covid viral load among the Tabligh participants was high, due to the extreme proximity, namely overcrowding in a small zone with poor ventilation, sleeping, listening to lectures, eating, praying together in close proximity and the culture of handshaking, hugging, kissing as a show of love and brotherhood among the Tabligh fraternity.

1545/3483 cases (44.36%) were linked to the Ijtima’ Tabligh at Sri Petaling (data as at 4/4/2020).

If the total Tabligh positive cases are known, a crude non-robust analysis can be made comparing Tabligh CFR (case fatality rate) versus CFR others.

The MOH has detected five generations of positive Covid cases that were linked to the Tabligh gathering. 711 cases had infected their families

The domino effect of the Tabligh contagion has been most damaging. Early reports confirmed 50 cases in Brunei, 13 in Cambodia, 5 in Singapore and 2 in Thailand. 700 participants from Vietnam, the Philippines and Indonesia were being investigated.

It has spawned two sub-clusters in our backyard, the Bangi wedding sub-cluster with 94 positive cases and the Rembau sub-cluster with 27 cases.

Knowing the universal and grassroot appeal of the Tabligh persuasion, this I think is one of the foremost challenges which must never be lifted off our Covid-19 radar.

2. The Indonesian Cluster

My politically incorrect reference to the Covid-19 time bomb across our waters has since gained traction. Indonesia has overtaken us with the highest numbers of positive cases in the ASEAN region with a high case fatality rate of 8.8%.

Their Covid-19 cases skyrocketed to 5,000 cases within a space of six weeks, unlike in Malaysia which took three months.

It is a chilling thought that we may potentially see the importation of Covid-19 through our porous borders, having suppressed the growth rate of our indigenous positive cases.

Unlike the earlier failure, whereby the-then Minister of Home Affairs allowed the Ijtima’ Tabligh to take place, failure to enforce strict controls over our Malaysian-Indonesian borders may unleash an even more threatening Indonesian Cluster.

3, The Marginalised Cluster

We may risk an upsurge of Covid-19 positive cases if we take our eyes off our refugee and migrant sub-population. The latter is wreaking havoc in our southern neighbors.

The Dormitory Cluster in Singapore, comprising work permit holders residing in foreign worker dormitories, as at 18 April 2020, numbered 2887, a whopping 48.2% (total 5992) of their total census.

This trend is not expected to slow down as yet, not until Singapore’s circuit breaker measures takes effect.

Apart from our migrant workers, Malaysia has to contend with a burgeoning refugee population of about 175,000.

The first scare was when it was reported that a substantial number of the refugees had attended the Ijtima’ Tabligh in Seri Petaling. This was however aborted with the rapid intervention of the CPRC (Crisis Preparedness and Response Center) in collaboration with NGOs (non-government organisations) working on the ground with the refugee community.

4. The Health Care Worker (HCW) Cluster

Like my earlier contestation on non-flattening of the curve and the infamous PPE (personal protective equipment) shortages, which by the way the MOH later acknowledged depleted supplies (press release on 13/4/2020), this will be another hot potato issue.

I cannot fathom why the MOH is denying that our HCW are spared of Covid-19 infection in their line of duty.

Reports from Europe states that 1 in 10 doctors and nurses in Spain and Italy has been infected by SARS-CoV-2.

Dr Eric Topol, physician, scientist and chief editor of Medscape, referenced an Iowa report where 1 in 5 of the Covid-19 infections were in the healthcare workforce. Many of these were related to the lack of PPE and this has compromised patient care. He adds that this was inexcusable.

And the body count among doctors alone has numbered 340 dead and climbing.

In a press coverage on 11 April 2020, it was announced that: “ 224 MOH health care workers have tested positive for Covid-19 as of today, but he stressed that none of the cases involved handling coronavirus patients in Covid-19 or intensive care unit (ICU) wards.”

However the discerning researcher will immediately note that in the same news report:
a) 41 cases (18.0%) of MOH staff contracted the virus from patients (this is classified as nosocomial infection which HCW acquire from the hospital setting). This includes:
– 29 cases (13.0%) from patients with SARI (Severe Acute Respiratory Infections) another source of HAI (Hospital-Acquired Infections).
– 9 cases (4.0%) from patients whose status were unknown and
– 3 cases (1.2%) from screening and other activities on the field.
b) 33 cases (15%) still under investigation.

A HCW cluster of 31 cases is looming in three hospitals in Sabah, Queen Elizabeth 2 Hospital; Women and Children’s Hospital, Likas; and Keningau Hospital and the MOH insists that “none of them were infected while handling Covid-19 patients”.

We’ve learnt from the grapevine that 17 nurses in an MOH Covid-19 hospital tested positive. We await confirmation or otherwise of this unofficial news.

The nuances from the MOH seems to suggest that our HCW are somewhat “immune” to hospital-acquired Covid-19 infections.

With the cry for PPEs from our health care workforce on the ground and the admission of the MOH on the depleting supplies of PPE, it is not too difficult to anticipate breakthrough Covid-19 infections among our HCW.

We, the rakyat, must therefore be uncompromising in our quest to protect our frontliner HCW with adequate and appropriate PPEs.

Clapping our hands from our apartment verandahs and blaring our motor car horns helps to boost our HCW morale, but more importantly we must sound to the higher authorities, the MKN (Majlis Keselamatan Negara) and its operative NADMA (National Disaster Management Agency) and the MOH, to unfailingly arm our HCW with enough and proper PPEs to wage the war against the invisible enemy or risk morbidities and mortalities among our largely young house-officers, medical officers, nurses and allied health professionals.

It is for these “voice-less” junior doctors, nurses and other HCW that I will unflinchingly raise the proverbial Covid-19 red flag to ensure their physical health, their emotions, their welfare, the welfare of their loved ones and their very lives are protected.

God bless our HCW.

Dr Musa Mohd Nordin is a paediatrician and chairman of the FIMA Advisory Council.

  • This is the personal opinion of the writer or publication and does not necessarily represent the views of CodeBlue.

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