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Covid-19 in Malaysia: A Pediatrician's Public Health Perspective

Summary:
From its first three imported cases on 25 January 2020, Malaysia has 9,200 positive cases with 125 deaths (15 August). The case fatality rate is 1.36%. 3, 375 cases and 34 deaths were from an international Tablighi Jamaat event in Kuala Lumpur. 20 percent of the total cases were 18 years and below. Most pediatric cases were mild or asymptomatic. The youngest was a new-born baby. There had been no paediatric deaths. The youngest Covid-19 death is 23 years of age, the oldest, 96 years.
This paper explores the contribution of population structure, health infrastructure, accessibility and expenditure, and decisions made by the Government and the Ministry of Health to the successful capping of transmission and deaths.
Malaysia’s population of 32.7 million has a median age of 28.9 years with 6.7 percent who are 65 years of age and older. Although its total health expenditure is 3.9 percent of GDP and only 50 percent is funded by the government, the public health and hospital facilities are of high standard, accessible to most, and largely free.
Covid-19 cases (including clinically suspect ones) are immediately admitted to designated hospitals regardless of symptom status. They do not have to pay for any of their medical and quarantine costs regardless of severity or duration of stay.
Physicians learnt from China and each other with regular web case reviews. Initially Hydroxychloroquine was used early for symptomatic adult patients in low dose and with close monitoring. Robust contact tracing and active case detection with targeted testing in high risk communities have cut down transmission.
The public cooperation with MCO, social distancing, wearing of face masks in public spaces, comprehensive contact tracing and frequent hand-washing is the key to long term capping of transmission, while the government tests and quarantines incoming travellers to prevent imported cases.
N.B: This is a country report on Malaysia and its situation regarding COVID-19 reviewing information which has been made public currently.

Malaysia is one of a few countries whose early hospitalisation and epidemic control measures have kept Covid-19 infections and deaths relatively low. As of 15 Aug, Malaysia (population 32.7million) had 9,200 confirmed cases with 125 deaths (1.36% Case Fatality Rate) compared to Japan (pop.125.96 mil), 55,049 cases,1,093 deaths (1.98% CFR) and USA (pop 328.24 mil), 5.37 million cases, 169,000 deaths (3.15% CFR). [1]

Covid-19 Timeline in Malaysia

On 24 January 2020, eight tourists from China arriving via Singapore had to be tested and quarantined in a hotel in Johor Bahru, West Malaysia. Singaporean authorities had informed that one of their travel companions from Wuhan had tested positive in Singapore on 23 January, its first Covid-19 case.[2] Three tested positive on 25 January, the beginning of the epidemic in Malaysia.[3] By 31 January, Malaysia recorded 22 cases, all imported.[30] The first Malaysian case was a 41 year-old male confirmed on 4 February. He had recently travelled to Singapore.

An international Tablighi Jamaat religious gathering in Kuala Lumpur (27 Feb -1 Mar) spiked the largest and most deadly cluster. There were an estimated 14,500 local attendees and 1,500 from many countries. By 16 March, Covid-19 had spread to all 13 states and 3 federal territories in Malaysia with 673 cases, more than half linked to the Tablighi event. Transmission from this cluster only ended in July with 3,375 local cases (42,023 samples tested) and 34 deaths.[4]

Brunei, Indonesia, Singapore, Thailand, Cambodia, Vietnam, and Philippines have traced their many cases to this gathering.[5]

Movement Control Order 18 March - 12 May 2020

On 17 March Malaysia reported its first two Covid-19 deaths, a 60-year-old pastor in Kuching, Sarawak and a 34-year-old from the Tablighi cluster. The substantial number of cases reported domestically following the Tablighi gathering led the Government to implement lockdown via a Movement Control Order (MCO) nationwide, beginning from 18 March to 14 April, and extended until 12 May.

During the MCO a person is not allowed to go out (even within states) unless he needs to: perform an official duty; visit a premise considered 'essential service'; purchase, supply or deliver food or daily necessities; seek healthcare or medical services. Only one representative of a family can go out to purchase daily necessities. The penalty is a fine of RM 1,000 (US$ 241) or jail up to six months', or both. The restriction bans mass gatherings and overseas travel. All educational institutions, businesses and premises were closed except essential services.

Most businesses were allowed to open on 4 May under strict standards of practice. Cinemas, theatres and other live events (e.g. places of worship) reopened from 1 July with a limit of 250 people. From 15 July, family entertainment centres including karaoke outlets and gymnasiums resumed business. However, discos, pubs, and night clubs cannot reopen yet (as of Sept.).

Public and private pre-schools, kindergartens, nurseries and day care centres resumed operations from 1 July. Schools began reopening in stages from 24 June with examination years. Years One to Four primary school (7-10 years old) pupils were the last to return to school on 22 July. Universities continue to be online.

It became compulsory for people to wear face masks in public spaces such as markets and public transportation from 1 August, with violators facing a RM1,000 (US$241 fine).

Covid-19 in Malaysian Children

The only publication on Paediatric COVID-19 is in the International Journal of Infectious Diseases, Four Paediatric Cases in Malaysia by See KC et al.[6] The cases, detected 24 Jan - 4 Feb, were of children, 20 months to 11 years of age. All four had history of recent (19 Jan - 4 Feb) travel from Wuhan and Foshan and had probably contracted the virus in China. Three were China nationals. The only Malaysian child had visited Wuhan for Chinese New Year with his mother who originated from Wuhan. All were mostly asymptomatic or had mild symptoms and were managed symptomatically. None required antiviral therapy.

There is currently no official up-to-date published report on the incidence of Covid-19 in Malaysian children. All available data in this article have been gleaned from internet reports of the daily briefings of the Malaysian Director General of Health (DG).

In the DG's (23 June) statement, of the 8,590 cases, 20 percent (1,712) were aged 18 years and below. 346 (4.0%) were between 16-18 years of age. There have been no deaths or intensive care unit cases in this age group up to date.[7]

On 16 May, 317 cases were under 12 years of age, of which 112 were below 4 years old and 22 were below one year.[8]

On 28 April, a new-born was diagnosed with Covid-19 after being born to a mother who had Covid-19. It had not been ascertained whether the infection had taken place before the baby was born or after. No further details are available about this case.[9]

A 12 day infant was the youngest Covid-19 patient in an earlier 28 March report.[10]
To date, there have been no deaths and no Kawasaki-like cases amongst children with Covid-19 in Malaysia. As Kawasaki syndrome is not a notifiable condition, it is not known if there has been any increase of such cases in 2020.[11]

The youngest Malaysian Covid-19 death so far is a 23 year old female university student with thyroid disease. [12] The oldest death is 101-year-old.

Socio-economic and Health Status of Malaysia in Comparison to Japan

Bloomberg Health Efficiency Index ranks Japan 7th and Malaysia 29th out of 56 countries.[13] This index ranks countries with a minimum population of 5 million, average lifespan of at least 70 years and GDP per-capita exceeding US$5,000. The latest index is based on 2015 data of the World Health Organisation. Of the 56 countries, Japan ranked 7th with an efficiency index of 64.3%, life expectancy 83.8 years, and health expenditure per-capita of US$3,733 (10.9% GDP). Malaysia ranked 29th (50.4%) with a 75.1 years life-span, and US$377 (3.9% GDP) total health expenditure. USA ranked amongst the least efficient (54th) with lifespan 78.7 years, despite having the world's second highest per-capita healthcare expenditure of US$9,536 (16.8% GDP).

The World Bank classifies Malaysia as an upper middle-income country with a GDP per-capita of US$11,721 in 2017 (Japan US$48,294). Its total land area is 330,289 km2 (Japan 364 555 km2). The population is 32.7 million (2020) with a population density of 99/km2 (Japan 348/km2). The two land masses, Peninsular (West) Malaysia (131,587 km2) and East Malaysia (Sabah 74,398 km2 and Sarawak 124,449 km2) on the island of Borneo are separated over 1000 Km by the South China Sea. Borneo Island is the world's third largest island.[14]

Population Age Distribution

The population of 32.6 million (2019 estimate) includes 3.3 million non-citizens. The median age is 28.9 years compared to 48.4 years for Japan.[15] The population proportion 0-14 years is 23.3%, 15-64 years 70.0%. Only 6.7% are 65 years and older.[16]

According to 2014 estimates in Japan, people aged 65 and older make up 25.9% of its total population, estimated to reach a third by 2050. 33.0% of Japanese is above the age of 60 (Malaysia 10.3%) and 12.5% are aged 75 or above. The number of children (aged 14 and younger) decreased from 24.3% of the population in 1975 to 12.8% in 2014. [17]

Malaysia is undergoing a demographic transition as the total fertility rate has fallen to 2.1 births per woman (Japan 1.4). The Infant Mortality Rate is 5.2/1000 Life-birth (Japan 1.6). Death below 5 years of age is 6.1/1000 LB (Japan 2.2).

The 2019 Male to Female ratio is 102:100 (Malaysian citizens) and 163:100 (non-citizens). In 2015, Japan had 95.55 males per 100 females.[18]

The Government of Malaysia launched the Malaysia My Second Home Programme in 2002 to allow foreigners who meet specified criteria to stay in Malaysia longer, with a renewable 10 year multiple entry social visit pass. Some 40,000 applications have been approved to date.[19] The Annual Global Retirement Index for 2020 voted Malaysia 7th among the top ten best places to retire and scored its health care accessibility and affordability at 93%.[20] According to the International Living website, in the category of Best Healthcare in the World for 2019, Malaysia ranked first with its world-class healthcare services and sophisticated infrastructure.[21] [22]

There is no National Health Insurance in Malaysia. The public health system is heavily subsidized through general revenue and taxes collected by the federal government. The Private sector is funded by private health insurance, out-of-pocket payments from consumers or employers. Since 1995, Managed Care Organisation (MCO) serve as third party payers. In 2017, the total health expenditure was Rm 57,361 million (US$13,747 mil) with 43.1% from the Ministry of Health, 37.6% private household out-of-pocket, 7.2% Private medical insurance, 1.2% MCO and 10.9% agencies and corporations.[23]

In 1957, Malaya gained independence from the British and joined Sabah, Sarawak and Singapore to form Malaysia in 1963. The British left a single provider, government funded health system with hospitals and polyclinics in the urban areas, maternal and child health clinics (MCHC) and mobile dispensaries covering the rural. This started to change in the 1980s due to the growing demand and higher expectation for healthcare following rising income, urbanisation and the expanding middle class. Private clinics, hospitals and laboratories have become affordable and time-saving alternatives.

For citizens, the fees for outpatient consultation and treatment are free in the MCHC and rural clinics. It cost only Rm1 (US$0.24) to see a government doctor in the urban outpatient clinics and Rm 5 (US$1.19) when referred to see a government specialist (Rm 30 if referred by private GPs). All prescribed medicines (on the Ministry of Health Drug List) are fully subsidised by Government and given free.

For non-citizens, consultation with a government outpatient doctor will cost RM40(US$9.65), and a specialist, RM120(US$29), without medications or treatment. Private General Practitioners charge RM20-30(US$4.80-7.24) per consult. Private specialists charge RM60-200(US$14.5-48.3) depending on complexity of case. Private practitioners prescribe medicines from their own dispensary in the clinic, so their patients do not have to find a pharmacy to buy the prescribed items.

There are 6,801 private clinics compared to 2,860 Ministry of Health clinics (in 2013). The private clinics are mainly small practices with single or a few practitioners.[22]

Patients can walk in and be seen by their doctor of choice, at their point of need with no need for appointments or long waiting time (unlike in government clinics). Private laboratory or radiological services are readily available. This is why the private sector is preferred for the personalised service, convenience and timeliness. After the initial diagnosis is confirmed, patients (e.g. cancer, surgical, chronic medical cases) may be referred to the government hospital or clinic for continuation of care to save costs. Mandated childhood vaccinations are free of charge to citizens through the government MCHCs. Those who can afford may choose to pay for them at the private paediatricians or GP clinics.

There are 144 Government Hospitals (42,290 beds) and 240 private hospitals (15,570 beds) in 2018.[24] Hospitalisation ward charges to Government hospitals depends on the class to which patient wish to be admitted. The quality of treatment is the same regardless of class. Admission to first class ward (with air-conditioning) is RM60-120(US$14.5- 29.0)/night, second class RM40(US$9.65)/night and third class RM3(US$0.72)/night. Daily medical charges are standardised to per day of RM15/RM5/free respectively regardless of medication costs or attention needed. Non-citizens' treatment charges are RM100/day and ward charges Rm160-320 depending on class. A normal delivery will cost RM300(US$72.4) /RM150(US$36.2) /RM10(US$2.41) for first/ second/third class and caesarean section RM800/400/100 (inclusive of specialist fees and operative procedures).[25]

All charges are exempted for the treatment and admission for any type of notifiable communicable infectious diseases (e.g. Covid-19, HIV,TB). Covid-19 cases are not charged for anything at all for the ICU, hospital stay, treatment, food and quarantine etc.

For other type of sickness, charges may be waived or a special discount given, based on the following criteria: income below RM300/month (US$72.4); holding a Social Welfare or National Islamic Council (MAIK) card; Disabled person; Student or Government servants. Malaysians who hold certain positions in the government, e.g. army, higher executive posts, are automatically admitted to first class wards and treatment paid for by the government.[26]

Doctor to Population Ratio

Malaysia [27] has 1 doctor to 454 people (2020) compared to Japan [28] 1:390 (2018). This is an improvement from the World Health Organization's Global Health Workforce Statistics on Physicians per 1000 population [29] comparing Japan (2016) 2.4, to Malaysia (2015) 1.5, and USA (2017) 2.6. The hospital beds per 1000 population were Japan (2012) 13.4, Malaysia (2015) 1.9, and USA 2.9 (2013).

The Malaysian Response to COVID-19: Building Preparedness for Surge Capacity, Testing Efficiency and Containment[30].

Malaysia started planning and preparing once the news about unusual cases of acute respiratory illness in China broke in late December 2019. The experience with MERS and SARS (2002-2003) and public health teams with expertise in contact tracing enabled an efficient response.

Procurement of diagnostic reagents started in January 2020. Renovations to hospital facilities were done in February 2020 to increase the critical care beds by 89%. Since ventilators were difficult to buy, in view of world-wide shortage, the increase from 526 to 1034 units was made possible by loans from private hospitals. The diagnostic laboratory capacity was also increased by 86% with the training of teams in the university research institutes and private laboratories.

Unlike most countries, Malaysia hospitalises cases as soon as they test positive, whether symptomatic or asymptomatic. Individuals with Severe Acute Respiratory Illness, close contacts with confirmed cases, or with travel history to high risk areas are also admitted for tests and monitoring. Only 58 designated hospitals are allowed to admit Covid-19 cases. The Government pays for all the costs, so it is totally free for patients.[31]

Learning from Chinese experience that lower doses of Hydroxychloroquine (HCQ) were effective, Malaysian specialists prescribed it early for all symptomatic patients with ECG monitoring. Azithromycin was not used with HCQ. Various combinations of HIV drugs (Kaletra), interferon, and anti-inflammatories were used.

WebEx (online) meetings were held twice a week among COVID-19 front-liners nationwide. All Covid-19 deaths were reviewed to see how best to improve clinical management and to share recommendations.

On 19 June, it was reported that of 28,512 Malaysian Health Care Workers have been screened, 363 were confirmed positive. Majority of cases were community acquired (religious gathering or weddings).[32] Only one health care worker has died from Covid-19. Two doctors died from Covid-19 acquired from travel (Turkey) and community.[33]

Malaysia's success is a combination of early preparedness and planning, experience in previous pandemics, diagnostics, public health system, comprehensive and prompt contact tracing, active case detection and a strict lockdown. The socio-demographic factors of a younger population may also account for the lower death rate. Malaysia continues to perform 0.3 tests /1000 population with a positivity rate of 0.2%.[34] (compared to Japan 0.2/1000 with 4.5% positive rate) [35]


References
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  3. Timeline of the Covid-19 pandemic in Malaysia https://en.wikipedia.org/wiki/Timeline_of_the_COVID-19_pandemic_in_Malaysia
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  8. Covid-19: 317 cases detected among children under 12 years old. The Star by Ashley Tang, 16 May 2020.
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  10. 12-day-old infant youngest Covid-19 patient. MSN news by Faiz Zainudin, 26 March2020.
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  11. No Kawasaki cases amongst children with Covid-19 in Malaysia New Straits Times by Nur Ain Mohamad Radhi, 20 May 2020.
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  28. Number of physicians engaged in medical care per 100,000 inhabitants in Japan from 2000 to 2018
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  29. Physicians per 1000 population
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  30. The Malaysian Response to COVID-19: Building Preparedness for Surge Capacity, Testing Efficiency and Containment
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  32. COVID-19 among Health Workers in Germany and Malaysia, Albert Nienhaus and Rozita Hod. International Journal of Environment Research and Public Health 7July 2020.
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  33. Saluting our Covid-19 frontliners
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  34. https://ourworldindata.org/grapher/daily-tests-per-thousand-people-smoothed-7-day?tab=chart&country=JPN~MYS
  35. https://ourworldindata.org/grapher/positive-rate-daily-smoothed?tab=chart&country=JPN~MYS
Profile

tan_poh_tin.jpg Poh Tin Tan
MBBS University of Malaya 1976
MSc Community Health for Developing Countries, London School of Hygiene and Tropical Medicine 1981
MRCP Pediatrics UK 1989
Diploma Public Health UK 1981
Fellowship in Hospitals for Sick Children, Edinburgh & Great Ormond Street


Pediatrician, Public Health Specialist, Retired Associate Professor.
Medical and disaster relief volunteer (Afghanistan, Aceh, Yushu, Palu, Niger, Nepal, Cambodia)
Passionate about training: Illiterate village health promoters, untrained traditional midwives, Paramedics and medical students and postgrads.
Public health educator on radio, newspaper and social media columnist; Member National Consultative Council for Children, Malaysia 2015-2019; Member, Sarawak Woman’s Council, 1996-2002, 2009-2010.
Life Mission: Doing Good, Healing All
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