KUALA LUMPUR, Feb 15 — About one in 10 killed by Covid-19 in Malaysia, or 94 out of 896 victims, died at home, as of February 8.
About 42 per cent of brought-in-dead (BID) cases were confirmed as Covid-19 positive more than two days from death, raising questions on whether the victims were buried before test results were released.
Although more than half of the 94 BID cases were reported in Sabah, Labuan had the highest BID incidence rate at about 30 cases per one million residents, followed by Sabah’s 13 cases per million population.
The capital city of Kuala Lumpur had the third highest BID incidence rate in Malaysia, 10 times lower than Labuan, at about three cases per million people. Selangor, the country’s most developed state, recorded the fourth highest BID incidence rate at nearly three cases per million population.
The recent surge of BID cases, allegedly due to Covid-19 infection, has caused much anxiety and concern in both the health care fraternity and the rakyat at large.
There have been some writings in relation to this painful issue. The Ministry of Health (MOH) has not been forthcoming in explaining the various factors contributing to this upsurge in BID and the remedial actions that have been instituted to mitigate this morbid trend.
It is extremely difficult to access information about this tragic course of events. This article is an attempt to put together information that is available in the public domain in order to understand the circumstances better and allay any fears in relation to our Covid-19 home isolation, home monitoring, and early intervention programmes.
Apparently, the first BID case was reported on 31 March 2020. Up until 8 February 2021, there have been a total of 94 cases of BID allegedly due Covid-19. This is approximately 10.5 per cent (94/ 896) of all Covid-19 deaths the country has witnessed until 8 February 2021.
Men made up 70 per cent of the total BID deaths. Nearly 64 per cent of those BID were Malaysians and the others were foreigners.
The majority of those BID, 68 persons (72.3 per cent), were aged above 50 years. The mean age of the BID victims was 60.92 years. Four people who were BID were less than 20 years old.
Five cases have been excluded from the ensuing analysis since they were reported as BID very early on in the pandemic. Their dates were reported as backdated cases and their authenticity cannot be verified.
The mean time from death to being confirmed as a Covid-19 death was 5.05 days (standard deviation: 7.81). This brings to question the type of tests that have been used to confirm the diagnosis Covid-19. It should strictly be the RT-PCR test, which has the best analytical sensitivity.
About 58.4 per cent were confirmed as Covid-19 positive within two days. It is disconcerting that 41.6 per cent were confirmed Covid-19 positive beyond 48 hours. In 17 per cent of cases, the turnaround time (TAT) of the confirmatory test was 11 days and beyond.
This also brings to question whether those who were BID and tested had been buried before the results were released. Were Covid-19 burial SOPs universally practiced prior to knowing the RT-PCR results?
Rapid antigen (RTK-Ag) testing would have given a rapid TAT whilst waiting for the RT-PCR results. And SOPs would have been religiously followed during burial rites to prevent transmission of the coronavirus to the handlers.
The majority of BID cases were reported from Sabah (55.3 per cent), followed by Selangor (18.1 per cent) and Kuala Lumpur (6.4 per cent).
Epidemiologically, the absolute number of BID cases tells us very little of the true picture of the burden of BID cases in the country and as a comparison between the respective states.
Expressing the number of BID cases according to the population paints a different picture altogether. Labuan, with only three cases of BID, has the highest incidence of BID cases at 30.1 per million population. This was followed by Sabah (13.3), Kuala Lumpur (3.4), Selangor (2.6), and Melaka (2.1).
About 62.8 per cent of BID cases had comorbidities. Hypertension (69.5 per cent) and diabetes (50.8 per cent) were the two main underlying medical conditions.
Perhaps this can be used as a benchmark by authorities as high-risk patients who can be quarantined in a surveillance centre so that medical attention is made available to avoid this dreaded complication.
This is an attempt at an interim analysis of BID cases in Malaysia up until 8 February 2021. Virtually all the data have been obtained from the public domain and personal communications.
BID cases made up 10.5 per cent (94) of all Covid-19 deaths in the country as of 8 February 2021. 70 per cent of the BID cases were men. Foreigners contributed 36 per cent of the BID cases, the rest (64 per cent) were Malaysians.
The average age of BID cases was 60.9 years. 72.3 per cent of the BID victims were more than 50 years old. There were four who were less than 20 years old.
The average time to confirm the BID as Covid-19 positive was five days. In 41.6 per cent of cases, the TAT exceeded two days and in 17 per cent of cases, the TAT was more than 11 days.
RTK-Ag testing would enable the dead to be buried under strict burial SOPs, whilst the confirmatory RT-PCR is still pending.
Even though the majority of BID cases were reported from Sabah (55.3 per cent), Selangor (18.1 per cent) and Kuala Lumpur (6.4 per cent), the incidence rate of BID cases was highest in Labuan (30 per million) followed by Sabah, Kuala Lumpur, Selangor and Melaka.
About 62.8 per cent of the BID cases had comorbidities. Hypertension (69.5 per cent) and diabetes (50.8 per cent) were the two main underlying health conditions and should signal a red flag to health care providers when monitoring these cases.
This interim analysis will enable health care providers to identify high-risk groups. These include the male sex, more than 50 years old, especially with hypertension or diabetes, and living in Labuan, Sabah, Kuala Lumpur, or Selangor.
They can be monitored more closely on digital apps and the use of oxygen saturation monitors should be made available either at home, in low-risk centres, or in Covid hospitals.
Apart from the factors discussed, there might be other confounding factors which might influence the fate of the BID cases. These include the victim’s social ranking (for example, bottom 40 per cent [B40]), accessibility to health care services, were they seen by a health care provider, what level of health care provider attended to them, did they miss the red flags, what treatment was prescribed, did victims comply with the health care provider counsel and treatment regime, and many others.
These must be examined closely and remedial actions undertaken to mitigate the risks. This is apart from public education to inform people of the early signs and symptoms of disease deterioration and how to access medical help.
The community should also be trained and empowered to assist their fellow neighbours who are Covid-19 positive and support them in terms of their essential needs, namely food security (food pack vouchers for B40, unemployed, day job workers); adequate and appropriate shelter; and provision of face masks, hand sanitiser, information pamphlets, including Health Assessment Tools (HAT), and oxygen saturation monitors. This also includes training and monitoring of high-risk persons only.
We hope to see a more rigorous and meticulous examination of the data of BID victims so as to better inform our health care providers to prevent, if not mitigate, these most unfortunate and tragic Covid-19 outcomes.
CodeBlue is publishing this analysis anonymously because the author fears repercussions.