Sick People From Red Zones Suspected Covid-19: MOH

By Boo Su-Lyn | 09 October 2020

Suspected Covid-19 cases must undergo 14-day quarantine if they don’t qualify for hospital admission.

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KUALA LUMPUR, Oct 9 — The Ministry of Health (MOH) has updated its Covid-19 case definition, expanding the list of clinical symptoms and including red zone visits to determine if a person likely has the coronavirus.

MOH has now replaced the “patient-under-investigation (PUI)” category with a new “suspected case” category. Medical facilities across the public and private sector must notify the nearest district health office on patients fulfilling the criteria for suspected Covid-19 cases, who will be served a 14-day quarantine order (home if suitable, quarantine station otherwise) if they are not admitted to hospital.

Health deputy director-general (public health) Dr Chong Chee Kheong wrote in an October 5 letter that MOH has updated its Covid-19 case definition after the World Health Organization (WHO) changed last August guidelines for case definition, in light of new scientific findings that coronavirus symptoms were not limited to just acute respiratory infection.

Besides WHO guidelines, he said MOH has also looked at the United States’ Centres for Disease Control and Prevention (CDC), case definitions in other countries, and the latest epidemiological studies on Covid-19 infection.

“These updated case definitions cover the case definitions for ‘suspected case’ and ‘probable case’, whereas the case definitions for ‘confirmed case’ and also ‘person under surveillance’ are retained,” Dr Chong wrote in his letter, sighted by CodeBlue, to state health departments, public university hospitals, as well as private medical groups.

“With the addition of the ‘suspected case’ case definition, the case definition for ‘patient under investigation (PUI)’ will no longer be used, and this category is now changed to ‘suspected case’.”

Who Is A Suspected Case Of Covid-19?

The definition for the now defunct Covid-19 PUI category previously stated that a person is considered a PUI if they have acute respiratory infection (sudden onset of respiratory infection with at least one of these symptoms: shortness of breath, cough or sore throat), with or without fever; and attended an event or areas associated with a known Covid-19 cluster, or travelled to or resided in a foreign country within 14 days before onset of illness, or had close contact to a confirmed Covid-19 case, within 14 days before onset of illness.

The new definition for a “suspected case” of Covid-19 now includes a much longer list of symptoms for consideration and an additional epidemiological criterion of visit to red zones, based on MOH’s 14-day moving charts of local coronavirus infections reported within mukim/ zones/ precinct in the past fortnight, as updated on the Crisis Preparedness and Response Centre (CPRC) Telegram account.

CPRC’s Telegram account and MOH’s Twitter and Facebook pages, however, only show 14-day moving charts delineated by large districts, without any case breakdown for smaller mukim/ zones/ precinct. A red zone is a district that reports 41 local Covid-19 cases and above within the past 14 days.

MOH classifies a “suspected case” of Covid-19 as a person who meets both clinical and epidemiological criteria, as listed below:

A. Clinical criteria

In the absence of a more likely diagnosis:

I. At least two of the following symptoms:

  • Fever
  • Chills
  • Rigors
  • Myalgia (muscle pain)
  • Headache
  • Sore throat
  • Nausea or vomiting
  • Diarrhoea
  • Fatigue
  • Acute onset nasal congestion or running nose

OR

II. Any one of the following symptoms:

  • Cough
  • Shortness of breath
  • Difficulty in breathing
  • Sudden new onset of anosmia (loss of smell)
  • Sudden new onset of ageusia (loss of taste)

OR

III. Severe respiratory illness with at least one of the following:

  • Clinical evidence of pneumonia
  • Acute respiratory distress syndrome (ARDS)

B. Epidemiological criteria

  • Attended an event or areas associated with a known Covid-19 cluster, or red zones;
  • Or travelled to / resided in a foreign country within 14 days before the onset of illness;
  • Or close contact to a confirmed case of Covid-19, within 14 days before the onset of illness.

“Close contact” is defined as:

  • Health care associated exposure without appropriate PPE (including providing direct care for Covid-19 patients, working with health care workers infected with COVID-19, visiting patients or staying in the same close environment of a Covid-19 patient).
  • Working together in close proximity or sharing the same classroom environment with a with Covid-19 patient.
  • Traveling together with Covid-19 patient in any kind of conveyance.
  • Living in the same household as a Covid-19 patient.

MOH has updated the case definition for a “probable case” of Covid-19 — which previously only included a person who tested positive on an antigen rapid test kit and is awaiting RT-PCR confirmation — to cover a suspect case with chest imaging showing findings suggestive of Covid-19 disease.

MOH noted, however, that radiological imaging procedure is not performed in all suspected Covid-19 cases unless there is clinical suspicion of pneumonia.

MOH’s definitions of a “confirmed case” and “person-under-surveillance” remain the same. A confirmed case of Covid-19 is a person with laboratory confirmation of Covid-19 infection, irrespective of clinical signs or symptoms. A person-under-surveillance for Covid-19 is an asymptomatic individual subjected to a home surveillance order.

Management Of Cases

Suspected Covid-19 cases from private clinics or hospitals shall be reassessed by a screening hospital or centre on the need for admission, with the screening facility then informing the admitting hospital if admission is needed. Suspected cases who do not fulfill admission criteria will be assessed for suitability of home surveillance.

All confirmed Covid-19 cases, whose test results are confirmed in a laboratory, and all probable Covid-19 cases fulfill the criteria for hospital admission. Low-risk people who test positive on an RT-PCR test for Covid-19 and do not have any symptoms, or only have mild symptoms, can be admitted directly to low-risk Covid-19 quarantine and treatment centres, after discussion with the relevant physician.

Suspected Covid-19 cases who are clinically ill, based on the treating clinician’s judgment, as well as suspected cases with uncontrolled medical conditions, immunocompromised status, pregnant women, and very young and very old people (aged below two years or aged above 60 years), fulfill the criteria for hospital admission.

Suspected Covid-19 cases who do not fulfill the above criteria for hospital admission, but are not suitable for home surveillance, will be considered for admission to designated quarantine stations.

Below is a guideline checklist for the suitability of suspected cases to undergo home quarantine, which may be tailored from one patient to another:

  • Has a separate bedroom with en-suite bathroom (preferable); if not, common bathroom with frequent disinfection.
  • Has access to food and other necessities.
  • Has access to face mask, glove, and disinfectant at home.
  • Able to seek medical care if necessary and return with own private transport.
  • Able to adhere to instruction to follow a home surveillance order.
  • Able to stay away (at least two metres apart) from high-risk household members (for example, individuals above 60 years old, young children below two years, pregnant women, people who are immunocompromised or who have chronic lung, kidney, heart disease).

If home surveillance is deemed suitable, suspected cases for Covid-19 will be sent home and put under a home surveillance order for 14 days. Suspected coronavirus cases will be notified to the district health office.

The Ministry of Health’s flow chart of management of suspected Covid-19 cases who are not admitted to hospital. Graphic from the Ministry of Health.

Impact Of New Covid-19 Case Definitions

Categorising people as “suspected cases” of Covid-19 — if they have symptoms and visited red zones — could mean potentially thousands of people living in or having travelled to red zones being sent to 14-day home quarantine after they seek treatment for conditions like the flu, which shares similar symptoms as Covid-19, like fever, chills, headache, sore throat, and running nose.

As of yesterday, 10 districts in Malaysia have been classified red zones: eight in Sabah, Klang (Selangor), and Kota Setar in Kedah.

Senior consultant paediatrician Dr Amar-Singh HSS said it was good that MOH has expanded the case definitions for suspected Covid-19 cases, in light of the growing epidemic in the country, especially in Sabah and Kedah.

“These new wider case definitions will necessitate a dramatic increase in testing capacity to cope with the volume. Tests must come back promptly to be of use, preferably within 24 hours.

“Use of antigen testing kits to support PCR testing is vital to speed up the process. We hope the government will allocate increased resources to MOH and the affected regions to support testing requirements,” Dr Amar told CodeBlue.

Health director-general Dr Noor Hisham Abdullah said yesterday that Malaysia is currently facing its third Covid-19 wave. Since October 1, MOH has been continuously reporting three-digit cases every day. On October 6, Malaysia reported the highest daily tally since the Covid-19 outbreak at 691 cases. Yesterday, MOH reported 375 new cases.

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