Klang Hospital Mystery: Two Index Cases, Over 140 Covid-19 Infections

By Ashswita Ravindran | 21 December 2020

The Covid-19 outbreak in Klang Tengku Ampuan Rahimah Hospital (HTAR), which started 3-4 weeks ago, caused the temporary closure of five wards in the medical and nephrology departments; they’re now running on lower manpower.

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KUALA LUMPUR, Dec 21 — The origins of a major Covid-19 outbreak in Klang’s main public hospital remain unknown, as staff say that full protective gear is always worn and patients are screened for coronavirus.

The outbreak in Klang Tengku Ampuan Rahimah Hospital (HTAR) has recorded a whopping 143 positive Covid-19 cases as of yesterday since infections were first detected three to four weeks ago, involving 62 medical staff and 81 patients at the Ministry of Health (MOH) facility.

CodeBlue spoke to two staff members from HTAR, both frontliners who gave a joint anonymous comment on the Covid-19 outbreak in the major tertiary hospital serving Klang, a huge district in Selangor with an estimated population of between 1.3 million and 1.5 million.

According to CodeBlue’s sources, the outbreak started when two doctors from two different departments — the emergency department (ED) and nephrology department — tested positive for Covid-19 in the same week, which was about three to four weeks ago. The HTAR staff told CodeBlue that the doctor got tested after developing symptoms of Covid-19.

“First in ED, then in the same week, cases were reported in the nephrology team,” the anonymous sources said.

The first Covid-19 case was detected in a doctor from ED, followed by a staff nurse, then a medical assistant who had contact with the staff nurse.

The anonymous sources explained that in ED, patients are categorised according to the urgency of care in the form of colours — green zone, yellow zone, red zone, and respiratory zone. In the red and respiratory zone, all the staff handling patients wear full personal protective equipment (PPE), which is the N95 mask with double three-ply mask, face shield, hair cover, boot cover, gloves, gowns, and apron.

While intubating a patient with unknown status, the staff wear the powered air purifying respirator (PAPR) PPE and the intubation procedure is done in an isolation room.

“In ED, full PPE is worn in the respi zone and red zone when intubating patients (which will be done in an isolation room).”

Besides that, those who require emergency intubation in ED will also be tested for Covid-19 using the RTK-Ag method, while patients who have severe acute respiratory illness (SARI) are tested for Covid-19 once in the ward.

“During the present worsening Covid wave, the majority are screened, regardless admitted or discharged,” the anonymous staff from HTAR said.

Meanwhile, in the yellow zone where minor to moderate cases are treated, patients are not tested for Covid-19 before entering the yellow zone, but symptoms are checked before entry and temperature screening is routinely done. All patients are also required to wear a face mask in the yellow zone.

“There were some cases. Patient positive for Covid-19 from a non-respi zone. Only got to know after doing the swab in the ward, but can’t help it because the patient was asymptomatic and tested positive,” HTAR staff told CodeBlue.

“However, there were no reports of cross-infection cases due to that.”

Covid-19 Infection Started In Nephrology Department Same Week

The Ministry of Health (MOH) has mobilised 668 nurses from within and outside Sabah to help with the state’s Covid-19 outbreak. Picture from Twitter @KKMPutrajaya.

Meanwhile, the infection in the nephrology department also started in the same week and was detected first in a doctor. The virus spread rapidly among staff of the nephrology department, leading to the temporary closure of five wards — medical and nephrology wards. The wards are now open but running at reduced manpower.

“All kidney failure patients who come with any sort of illness are admitted and tested,” the anonymous sources said, while pointing out that the testing method used is the RTK Ag method.

“Nephrology wards or cubicles are air-conditioned to maintain air filtering to avoid air contaminants.”

The haemodialysis machines are also sanitised fully and doctors and nurses attending to patients wear full PPE, the anonymous sources said. They added that it is common for patients to spread the coronavirus infection to the staff.

However, in this case it is difficult to pinpoint how the infection started both in ED and the nephrology department because the staff handling the patients were in full PPE. It could be that they got the infection from outside the hospital.

Nonetheless, even if the two index cases in the ED and nephrology department presumably brought the virus into the hospital, it is unclear how they infected their coworkers if staff were constantly wearing protective gear. The magnitude of the outbreak, touching nearly 150 cases in HTAR, poses questions on how infected staff or patients were not identified and isolated early enough to prevent further transmission of the virus.

Questions also remain on whether the health workers had infected the patients they were seeing, or whether some of the infected medical staff had actually contracted Covid-19 from patients — unconnected to the two doctor index cases. Movements in hospitals are very fast, especially in ED. The source of infection is still being investigated by health authorities.

MOH, in their guidelines of management of health care workers during the Covid-19 pandemic, stated that routine Covid-19 screening is done on targeted groups only and mass screening is not needed to be done routinely. Screening of targeted groups will also be done based on risk assessments.

The HTAR staff told CodeBlue that in their hospital, staff screening for Covid-19 is usually done when an employee comes into close contact with a positive case.

Today, Selangor Mentri Besar Amirudin Shari said that all HTAR staff will be screened for Covid-19 as they are considered high risk. Amirudin said that this will be discussed first with the Selangor State Health Department and the screening will be done soon.

Health director-general Dr Noor Hisham Abdullah said in a statement last Friday that the rise of Covid-19 cases among health care workers in the Klang Valley was likely linked to growing infections in the community. As of December 18, he said health care workers infected with coronavirus were detected in half a dozen government hospitals: HTAR (54 cases), Serdang Hospital (29 cases), Sungai Buloh Hospital (15 cases), Kuala Lumpur Hospital (10 cases), Ampang Hospital (5 cases), and Selayang Hospital (4 cases).

However, it is a possibility that the HTAR patients who tested negative with Covid-19 using the RTK-Ag method were still in their incubation period, hence they did not test positive at first and unknowingly infected health workers.

The RTK-Ag test has a sensitivity of 90 per cent, which means that 90 per cent will correctly return a positive result for 90 per cent of the people with the disease, but will give a mistaken negative result, or a false negative, for 10 per cent of the people who have the disease and should have tested positive. The RTK-Ag is usually done in urgent cases, as it only takes 15 minutes for results to be ready.

Situation In HTAR Still Under Control

A swab taken for Covid-19 testing. Picture from Dr Noor Hisham Abdullah.

The anonymous sources said that HTAR started sending stable patients to Banting Hospital since last week, but only a minimum number of patients were sent, around less than 10 of them.

“(The situation is) still under control because the ones who got infected at the first stage are all back to work.”

Anonymous frontliner from Klang Tengku Ampuan Rahimah Hospital (HTAR)

“We took extra manpower from other departments to run the show.”

The anonymous sources also said that it is difficult to trace back the patients that came into contact with Covid-19 positive staff, but now, almost all patients are swabbed and screened for Covid-19.

“Those who are at high risk of Covid-19 and those with symptoms are definitely screened.”

Set Up A Klang Covid-19 Response Team: Klang MP

Klang MP Charles Santiago at a press conference on November 17, 2020, in Parliament. Picture courtesy of DAP.

Klang MP Charles Santiago, in a statement today, urged MOH to set up a Covid-19 response team that could involve MOH federal and state officials; health-based non-governmental organisations (NGOs); professional bodies such as the Malaysian Medical Association (MMA) and Malaysian Public Health Physicians Association; the Klang Municipal Council, and the Klang business community.

He said that even before the HTAR outbreak was first reported in the media last Thursday, there were already rumours about a breakout of Covid-19 cases in the public hospital.

“And even more speculations about a possible cover up. There may be no basis to this gossip but the point is that people were panicking,” Charles said in a statement.

“It’s incredibly difficult to keep issues hushed up. More so when people are frantic about the rising numbers of Covid-19 cases.”

According to the DAP lawmaker, over the past two weeks, Klang and Kapar alone have recorded 3,724 positive Covid-19 cases and 10 deaths. Currently, there are 4,318 active infections.

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