1

ARTICLE 1: Nor Kamariah Noordinc, Azmawani Abd Rahmand, Zamberi Sekawie, Aini Iderisf,

Malaysian role in overcoming

the pandemic Mohamed Thariq Hameed Sultana,b,g,h,*
AB S TR AC T
COVID-19outbreakin
Malaysia: Actions Background: Coronavirus disease 2019 (COVID-19), a novel pneumonia disease originating in Wuhan, was confirmed by the World
taken by the Health Organization on January 12, 2020before becomingan outbreakin all countries.
Outbreak situation: A stringent screening process at all airports in Malaysia was enforced after the first case outside China was reported
Malaysian in Thailand. Up to April 14, 2020, Malaysia had reported two waves of COVID-19 cases, with the first wave ending successfully within
lessthan 2months.InearlyMarch2020, the second wave occurred, with worryingsituations.
government Actions taken: The Government of Malaysia enforced a Movement Control Order starting on March 18, 2020 to break the chain of
COVID-19. The media actively spread the hashtag #stayhome. Nongovernmental organizations, as well as prison inmates, started to
Ain Umaira Md Shaha, produce personal protective equipment for frontliners. Various organizations hosted fundraisingevents to provide essentials mainlyto
hospitals. A provisional hospital was set up and collaborations with healthcare service providers were granted, while additional
Syafiqah Nur Azrie Safria, laboratories were assigned to enhance the capabilities of the Ministry of Health. Economic downturn: An initial financial stimulus
Rathedevi Thevadasb, amountingto RM 20.0 billion wasreleasedinFebruary 2020, before the highlightedPRIHATIN Package, amountingto RM 250billion,
was announced. The PRIHATIN Package hasprovided governmental support tosociety, coveringpeople ofvarious backgrounds from
students andfamiliesto business owners.
© 2020The Author(s). PublishedbyElsevier Ltd on behalf of International Society forInfectiousDiseases.
Thisis an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-ncnd/4.0/).

Introduction
The world is currently experiencing a deadly infectious disease caused by severe
acuterespiratory syndrome coronavirus
*Correspondingauthor at:Department of Aerospace Engineering, Facultyof Engineering, Universiti
Putra Malaysia, 43400 UPM Serdang, Selangor Darul Ehsan, Malaysia
E-mail address:thariq@upm.edu.my (M.T.H. Sultan).
https://doi.org/10.1016/j.ijid.2020.05.093
2 (SARS-CoV-2), called coronavirus disease 2019 (COVID-19). The Director
General of the World Health Organization (WHO), Dr. Tedros Adhanom
Ghebreyesus, in his opening remarks at the media briefing on COVID-19 on April
10, 2020, announced that the COVID-19 outbreak had affected 213 countries,
with 1,524,162 confirmed positive cases and 92,941 deaths. COVID19 is caused
by a novel coronavirus (SARS-CoV-2) that infects the respiratory tract. About
80% of patients experience mild infections and recover. The remaining patients
have severe infections with dyspnoea and low blood oxygen saturation, or may be
ina critical state withrespiratory or multiple organ failure(WHO,2019).
Starting in early December 2019, this disease spread rapidly among the residents of
Wuhan City, Hubei Province, China. This was an unusual situation, with pneumonia
1201-9712/© 2020 The Author(s). Published by Elsevier Ltd on behalf of International Society for Infectious Diseases. This is an open access article under the CC BY-NC-ND license
(http://creativecommons.org/licenses/by-nc-nd/4.0/).
cases of unknown cause being reported. The Chinese government reported the virus
to the WHO on December 31, 2019 (Secon et al., 2020; WHO, 2020c). Indepth
investigations were conducted immediately, as the number of cases increased each
day. A Management Incident Support Team (MIST) was set up by the WHO on
January 1, 2020 at all three levels of the organization, putting it on an emergency
footing to deal with the outbreaks(Gralinski and Menachery, 2020).
Quick early findings showed thata number of patients had been exposed tothedisease
at the Huanan seafood market in Wuhan City. Besides seafood, various exotic foods
can easily be found in this market, such as bats, snakes, marmots, and birds. It is
generally knownthatexoticanimalsare highly susceptibletoandactas high potential
carriers of various viruses and bacteria, due to their eating habits and habitats.
Therefore, environmental samples from these animals sold in Huanan market were
analysed to identify the possible source of the bacterium or virus causing this
pneumonia disease (Gralinski and Menachery, 2020). The market was closed
starting onJanuary1,2020,oncethe outbreak wasannounced (Seconetal.,2020).
On January 7, 2020, the Chinese authorities identified a novel coronavirus (nCoV) as
the cause of this severe pneumonia disease, and the identification of nCoV was
confirmed by the WHO on January 12, 2020 (Secon et al., 2020; Abdullah, 2020a).
ThenCoV foundintheanimalsinthe market had causedanacuterespiratory infection
in humans. Several studieshave strongly suggestedthat bats werethe main host of this
nCoV, as the whole genome-wide nucleotide sequences of the nCoV were 96%
identical to bat coronavirus (Li et al., 2020). Various coronaviruses are found in
animals that cause not only respiratory diseases, but also liver, gastrointestinal, and
neurological diseases. However, there are only seven coronaviruses that can cause
disease in humans reported to date (Tesini, 2020). Middle East Respiratory
Syndrome coronavirus (MERS-CoV) and severe acute respiratory syndrome
coronavirus (SARS-CoV) are previously identified coronaviruses causing human
disease, with severe effects including fatality and respiratory infections. These two
viruses have caused major outbreaks of deadly pneumonia, severe acute respiratory
syndrome (SARS) and Middle East Respiratory Syndrome (MERS), and were
identifiedin2002 and2012,respectively(Tesini,2020;WHO, 2020d).
SARS-CoV-2, the novel coronavirus that originated in Wuhan, has now been added
to the list of viruses threatening humans. Figure 1 shows an image of SARS-CoV-2.
This virus has caused severe outbreaks of a pneumonia disease around the world,
named COVID-19 (WHO, 2020d). Compared to the earlier reported cases of
COVID-19, namely those occurring in the patients who visited the Huanan market,
the later cases had no similar history. This was an alarming situation, as the number of
cases in this second group increased significantly. The situation then became more
complicated, as some of the new cases were detected in patients with no travel history
to Wuhan (Chan et al., 2020). From these observations, it was suggested that human-
to-humantransmission could have occurred(Li etal.,2020).
The WHO has suggested that SARS-CoV-2 has an incubation period of 14 days and
can be transmitted within this period (Rothe et al., 2020; Quilty et al., 2020). The
transmission of SARS-CoV-2 can occur easily through respiratory droplets and
direct or indirect contact with the mucous membranes of the eyes, mouth, and nose.
People witha compromisedimmune system, suchasthe elderly and infants, as wellas
people with a background history of other diseases, are more likely to be severely
affectedafter being
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with a background of other disease are more susceptible to COVID-19, including

fatality (Lu et al., 2020; Carlos et al., 2020; Xia et al., 2020). A cold environment is
another factor that can make this deadly virus survive longer and spread actively and
faster. Therefore, countries with a higher population of elderly people and those with
cold climates have reported higher numbers of deaths and lower numbers of
recoveries. As at April 11,2020,Malaysia had reporteda total of 4346 casesanda total
of 1830 recovered. One major point that can be discussed here is that Malaysia is a
tropical country with temperatures of up to 40 C; this climate may help to limit the
spread ofthis deadly virus, which cannot survive longat such temperatures.
The total number of cases reported globally at the time the data were retrieved for
Table 1 was 1,699,632, with 102,734 deaths and 376,330 recovered. Figure 2
summarizes the fraction of the total number of active and closed cases around the
world.

Status oftheCOVID-19 outbreak situationin Malaysia

In Malaysia, the threat of COVID-19 became increasingly apparent when

neighbouring Singapore reported its first imported COVID-19 case from Wuhan,
China on January23,2020, which was also the first positive casein the republic. From
Figure 1. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), which has caused this first case, eight close contacts were identified as being in Johor, Malaysia
coronavirusdisease 2019 (COVID-19) (Powell, 2020).
(Abdullah, 2020b).
Within less than 48 h of the first case reported in Singapore, Malaysia reported its first
diagnosed with COVID-19 (Lu et al., 2020; Carlos et al., 2020; Xia et al., 2020). The COVID-19-positive case on January 25, 2020. This was an imported case from
symptoms of COVID-19 include a fever, dry cough, fatigue, nasal congestion, Wuhan,China (Abdullah, 2020c). Atotal of eightpositive cases werereported within
headache, diarrhoea, sorethroat,and vomiting(Wangetal.,2020;Huangetal.,2020). 6 days, starting from the first case. All of these cases were imported cases from China
(Abdullah, 2020d). The first Malaysian testing positive for COVID-19 was reported
Status oftheCOVID-19 outbreak situationglobally on February 3, 2020; this person had a history of travel to a neighbouring country for a
business meeting, which was also attended by a delegation from China (Ahmad,
ThefirstCOVID-19 caseoutsideChina wasreportedinThailand onJanuary13,2020, 2020).
2 daysafter China reporteditsfirstdeathon January11,2020 (WHO,2020c).Thiscase Overall, reported cases in Malaysia,asat March31,2020,can be divided into three
led to more stringent screening processes for passengers with a fever at airports in waves. The first wave was successfully handled by February 27, 2020, with all 22
Thailand,Hong Kong, South Korea,and Singapore(Secon etal., previously reported cases being discharged from hospital. Most cases reported in
2020).OnJanuary20,2020,the first case wasreportedin the United States,ina person the first wave were imported cases from China and their contacts. Only two cases
with a history of returning from Wuhan (Secon etal.,2020).The US declared nCoVas were found to have resulted from local transmission (Abdullah, 2020e). Table 2
a Public Health Emergency on January 31, 2020, the day after the WHO declared the shows the numbers of casesinthefirst wave of COVID-19 in Malaysia.
outbreak as a Global Public Health Emergency (Secon et al., 2020; WHO, 2020c;
A sudden significant increase in the number of positive cases was
Worldometer,2020).
reportedonMarch4,2020,withaslightlylowernumberthedaybefore (Abdullah,
On January 31, 2020, the first cases were reported in Sweden and Spain, while Russia
2020f,g).These new cases were foundto have beenin contact with case number 26,
and the United Kingdom reported their first two cases respectively (Worldometer, who had attended at least five different meetings or gatherings. The alarming high
2020; Department of Health and Social Care, 2020; Sofiychuk, 2020). At the time of number of cases reported
writing, SARS-CoV-2 was continuing to spread globally. Table 1 shows the top 10 originatedfromtheclusterofcasenumber26,withahistoryoftravelto Shanghai,
countries with the highest numbers of COVID-19 cases reported as at April 11, 2020 China. The cases reported within this period consisted of Malaysians (Abdullah,
(Worldometer, 2020). Many websites present the latest updates on the number of 2020g).
COVID-19 cases worldwide. The situation became worse on March 11, 2020 after the International Health
Five countries have exceeded the number of cases in China, where the virus outbreak Regulations (IHR) Malaysia was informed by
started. Many factorshaveaffectedthe IHRBrunei,thatonepositivecaseinBruneiwasfoundtohaveattended a religious
gatheringinSeri Petaling Mosque, Selangor,Malaysia from February27 to March
Table1
Top 10 countrieswith the highest numbersofCOVID-19 casesasat April 11, 2020 (Worldometer, 2020). 1, 2020. This gathering was attended by more than 10,000 participants from
No. Country Total cases Total deaths Total recovered different countries, with at least half of them coming from Malaysia (Abdullah,
2020h).
1 USA 502,876 80,747 27,340
The consequences of the religious gathering in Seri Petaling Mosque in terms of
2 Spain 158,273 16,081 55,668 COVID-19 cases were very significant. An alarmingly high number of new cases
3 Italy 147,577 18,849 30,455
were reported immediately after the news was received from IHR Brunei. More
4 Germany 122,171 2736 43,913
than 100 cases were reported each day, with more than 50% of cases having a
5 France 124,869 13,195 24,932
history of attending or contact with the new cluster from the religious gathering in
6 China 82,003 3342 77,525
7 Iran 68,192 4232 35,465
Seri Petaling (Abdullah, 2020i). This new cluster marked a bigger threat of
8 UK 73,758 8958 344
COVID-19 in Malaysia.
9 Turkey 47,209 1006 2423 The number or critical cases in the intensive care unit (ICU) increased each day,
10 Belgium 26,667 3019 5568 with the first two critical cases being reported on March 9,2020 (Abdullah, 2020j).
34 Malaysia 4346 70 1830 Malaysia reported its first fatal case on March 17, 2020, a case related to the
growth in number of cases, suchasthe size and population ofthe respective countries. religious gathering in Seri Petaling. Another death was also reported on the same
It would not be appropriate to judge the capabilities of the authorities in handling date from a case in Sarawak (Abdullah, 2020k). Figure 3 shows the numbers of
disease cases based on the number of total deaths and total recovered cases alone, as cases from March 10 to March 31, 2020, which involved the biggest cluster for the
the groups of infected cases are different in each country. As discussed earlier, those COVID-19 outbreak inMalaysia.
groups of people with a compromised immune system, the elderly, and individuals
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As at March 31, 2020, a total of 2766 positive cases had been reported to the
Ministry ofHealth(MoH), with537 recovered cases and43 deaths. This pointsto a
total of2186 active cases currently
Table2
being treated in hospitals and 580 closed cases (Abdullah, 2020i). The Malaysian
government together with the MoH, as the key player, has made tremendous efforts
to faceandhandle the outbreak during this periodandbeyond.
This paper discusses theactionstaken by variousinstitutionsin Malaysia,including
governmental and non-governmental organizations (NGOs), as well as its citizens.
The actions covered in this paper are limited to the period up until March 31, 2020.
TheCOVID19 outbreak in Malaysia is currently still ongoing, with high numbers of
casesreported each daytodate.

Actions takenby theGovernment ofMalaysia andMinistry of Healthtoovercome

COVID-19

Malaysian citizens did not initially realize how deadly the virus is. On January 25,
Figure 2. The numbers of active and closed COVID-19 cases around the world, as at April 11, 2020
(Worldometer, 2020).
2020, Malaysia showed no intention of banning travellers from China, although
China hadalready quarantined the
COVID-19-positive casesin the first wave in Malaysia, based on nationality(Abdullah, 2020e).
Date Chinese citizen Malaysian Other Total recovered

January25, 2020 to February27, 2020 15 7 1 22

Figure3. Total newcases, recovered cases, and deathsreporteddailyfromMarch 10 to March 31, 2020 (Abdullah, 2020i).

entire population of 11 million in Wuhan due to the deadly virus Moreover, an alliance involving 38 professional medical (The Star, 2020a). Malaysians were also not well
prepared to fight societies was established on March 1, 2020 to support the MoH the pandemic, mainly because of the political crisis that was in the area of healthcare (Malaysia
Health Coalition, 2020). The happening at the same time and also because they were assured intention of this coalition was to keep the community wellthat the virus would not
spread easilyin Malaysia. However, with informedand to ensure thatinformation madeavailable was true the number of positiveCOVID-19 casesinMalaysia increasingin and
accurate.
lessthana week from99 on March8 to200, withthefirst two Another measure taken by the MoH to cushionthe impact of deathsreported in mid-March,Malaysiansbeganto panic
(Majid, COVID-19 was the setting up of a special fund known as the COVID2020). Consequently, the government took many steps to alleviate 19 Fund, to raise money to be
channelled to patients, particularly the masspanicand protect the health ofMalaysian citizens. thoseaffectedfinancially duetothequarantine procedure.This
The MoH playeda crucialrolein ensuring maximumreadiness fund initiallyreceivedRM1 million from the governmentand tocontainthe spreadof the virus. Among the earliest
efforts taken private sectors. NGOs and individuals were welcomed and by the MoH to prevent disease transmission was the enforcement encouraged to direct their
contributionstoo.Throughthis fund, ofhealth screeningatall points of entry. AccordingtotheDirector- RM100 was given daily to those who hadno source of income General of
the MoH Datuk Dr. Noor Hisham Abdullah, one of the throughout the quarantine and treatment processes. In addition, strategies was the placement of thermal scanners
(Bernama, the money collected was used to cover medical expenses such as 2020a). This was done to further enhance the detection of fever buying crucial equipment and other
supplies. To further encourage amongst tourists and/or locals returning from abroad. Malaysians contributions, the Inland Revenue Board (IRB) took up the initiative who
returned from Wuhan were screened, identified, and isolated of offering tax deductions for cash and item donations to help the in special quarantine areas for COVID-19. This
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measure also affected communities in meeting their basic needs and help build involved airline crews as well as the staff of the MoH (Kaos, 2020). their resilience (The Star,
2020b).
The subsequentkey step taken by the MoH along withthe With regardsto funding, The MoH andTenaga NasionalBerhad government toovercome the spread of COVID-19 was
to increase (TNB) established an action coalition to obtain financial aid from the number of hospitals that could treat COVID-19 cases. There was corporate companies,
government-linked companies (GLCs), and also a group effort between public and private hospitals to other organizations in Malaysia in the move to fight the outbreak.
accommodate the growing numbers of cases of infection, The funds collected wereused by the MoH torestock medical comprisinguniversity hospitals and Ministry ofDefence
hospitals suppliesas wellas necessaryhealthcareitemsto curbCOVID-19
(TheEdge Markets,2020). (New StraitsTimes,2020a).
To enhance the MoH efforts in keeping the spread and mortality The MoH in its effort to counter COVID-19 infection also set up a under control, a Movement Control Order
(MCO) was implemented provisional hospital in the Agro Exposition Park Serdang (MAEPS) on March 18, 2020. The MCO related to the restriction of movement in
coordination with The National Disaster Management Agency. of people into or out of an area. The Director-General of the MoH This makeshift hospital, which was initially
Malaysia's largest emphasized that the order enforced came under the Prevention convention centre, is equipped with computers, televisions, Wi-Fi and Control of Infectious
Diseases Act1988 andthePolice Act1967 connection, a loungearea,and someother basic facilities for useby and would help to controlthe spread ofthe virus(Bernama, patients
and medical staff. This hospital is to be used as a 2020b). This step was significant, as the situation in China had quarantine and treatment centre for low-risk patients, and 604
proved that by isolating the infected group of individuals and beds have been prepared to cater for confirmed cases with or practicing social distancing, the pandemic could be
contained without symptoms ofCOVID-19,asthere isa possibility of cases
(WHO,2020a). peakingin the middle of April. Furthermore, as part oftheMoH
Qian et al. Infectious Diseases of Poverty (2020) 9:34

action plan, public halls and indoor stadiums will also be utilized if cases hit 1000 per day. Three thousand retired nurses will return as volunteers to fight
COVID-19 along with the country's frontliners (Ang,2020).
Apart from that, to further reduce transmission of the disease, the MoH urged the remaining participants who attended the tabligh gathering at Seri Petaling
mosqueto come forward for tests and/or screening. To make the detection processa success,the MoH has been takingaggressive measures by closely working
with the police to locate possible carriers of the virus, identifyingthem, carrying outtesting, and imposinga 14-day self-quarantine (Bernama, 2020d).These
efforts can also be seen through the collaboration oftheMoH with certainparticipating healthcare service providersthat offer swabtestingand the collection of
samples fromindividualsandcompanies within their premises,as wellasdrive-throughtest sites (Landau,2020).
One of the initiatives agreed after the Economic Action Council meeting held on March 23, 2020 was the allocation of RM 600 million to the MoH to battle
COVID-19. According to Prime Minister Tan Sri Muhyiddin Yassin, RM 500 million would be utilized to buy ventilators and personal protective equipment
(PPE) andanother RM100 million wouldbeused toappoint 2000 nurses ona contract basis(Yusof,2020).
OnMarch27,2020,whenannouncingtheRM250billionPRIHATIN Package to support micro, small, and medium-sized enterprises
strugglingtoretaintheiremployees,thePrimeMinisterannouncedan additionalbudgetofRM1billiontocaterformedicalneeds,suchasthe purchase of
equipment and services to overcome COVID-19. The Ministry also received support from the insurance sectors, both conventional and Islamic insurance,
wherebya RM 8 million fund was set up to bolster COVID-19 testing. Each policyholder could go for a
screeningtestworthuptoRM300inprivatehospitalsandlaboratories. Other thanthat, policyholderswithfinancialproblemsand disruption totheir incomeas a
result of the MCO and coronavirus outbreak were givena3-monthdefermentontheirpolicypayments.Thegovernment also showedits gratitudeto healthcare
employeesbyincreasingtheir monthlyallowancefromRM400toRM600permonthbeginningApril
1,2020,tobe continueduntilthe epidemic ends(Sunil,2020).
In addition, the MoH arranged various disinfection activities to be conducted by the Ministry of Housing and Local Government, local authorities, and the
DBKL(Kuala Lumpur City Council).This procedure hasbeenconducted mainly in high-risk areas(Bernama, 2020e).
The MoH has also sought to be transparent in handling the pandemic by providing sufficient and up-to-date information to the public through three major
platforms including the Official Portal of the MoH, creation of a special Facebook user account called the Crisis Preparedness and Response Centre (CRPC),
Kementerian Kesihatan Malaysia (KKM), and CRPC KKM Telegram (My Government, 2020).The Ministry has provided awareness programmes on basic
protective and hygiene measures to minimize transmission of SARS-CoV-2 in simple diagram form to reach the public easily. This includes hand-washing
techniques and the use of hand sanitizers and face masks. In addition, various infographics associated with COVID-19 have frequently been prepared and
uploaded onto the website. The MoH has also conducted daily press briefings, conference recordings, and has published relevant news on COVID-19 to
increase publicengagement and ensurepublicawarenessandaccess toaccurate information.

Actions takenby themedia, NGOs, and public institutions

Malaysia wasoneof thefirst countries to come out withvarious quick responsestoprotectits citizens fromCOVID-19.The main aim wastominimize economic
and social impacts, limitits spread, and provide care for its citizens. Many contributions were made by the citizens to overcome this pandemic,and this section
discusses theresponses fromother organizationsand communities.

Mainstreamand social media

COVID-19 has caused fear,anxiety, and confusion. The media, celebrities, and other influencers have appealed to the public to stay at home andavoid mass
gatherings. The media has started to use the hashtag #stayhome. This hashtag has been used widely in the media, and it is hoped that important messages to
stopthe spreadof COVID-19 canreachall levels of society.

NGOs

TheMCO hasaffected Malaysia's economy.Most companies havetheir employees working from home,and some workers have hadto stop working.NGOs
have beenactively helping those who areaffected bythispandemic.They have been providing food, shelter for the homeless, andhaveevengivenout money
to help thosein need.SomeNGOs have helped by providing protective masks, disinfection chambers (Bernama, 2020c),and helping to educate citizens on
COVID-19 (The Star, 2020c). All frontliners are required to wear PPE. However, due to the rapid increase in COVID19 cases, there have been shortages in
PPE equipment. This shortage could have endangered the health of frontliners. Therefore, several NGOs and public figures have helped to sew PPE for
medical frontliners. For example, several Malaysian fashion designers associated with the Malaysian Official Designers Association (Moda) have
produced PPE for local medical staff (Cheong, 2020). Prison inmates have also been involved in sewing protective gear for frontliners regardless of their
current situation (Chalil,2020). Volunteer tailors have helpedto prepare PPE for frontliners.

Publicinstitutions

Educational institutions, schools, and higher education institutions have had to close due to COVID-19. However, this has not stopped researchers from
various universities from helping citizens in fighting COVID-19. Universiti Putra Malaysia (UPM) for example has produced an instant hand sanitizer
(Sinar,2020) and face shields(New StraitsTimes,2020b). Universitiesand colleges have alsoraised fundsin order tohelp studentsaffectedby thevirus; for
example, UPM, UniversitiTeknologi Malaysia (UTM) (Rohizai,2020),and Universiti Malaysia Kelantan(UMK) (Nor Fazlina,2020).
Individual self-precautions

SARS-CoV-2 shares similar characteristics with SARS-CoV, and both viruses pose a global threat.Therefore, several measures have beentaken to haltthe
spread of SARS-CoV-2. This ‘new normal’ life has had an impact on Malaysian lives. For example, most people have started working from home (New
Straits Times, 2020c). Malaysians have even stated a preference to stay at home for future protection from germs and viruses, due to fear and anxiety when
going to the supermarket, on public transport, or traveling. They have also practiced wearing protective masks when out in public, frequent hand-washing,
andavoiding mass gatherings. As stated earlier,this virus can spread easily by direct transmission from symptomatic individualsto someone whois in close
contact via respiratory droplets, by direct contact with infected individuals, or through contact with contaminated objects and surfaces. The WHO (WHO,
2020b) has suggested that humans avoid consuming meat from regions affected by COVID19, avoid direct contact with symptomatic people, and avoid
travellingtohigh-risk areas.

Malaysianresearchers

This pandemic has created opportunities for Malaysian researchers to play their part by developing different technologies to help Malaysians facing the
pandemic. Examples of these developments include COVID-19 rapid test kits (Gomes, 2020), the creation of face shields using 3D printing, laser cutting, or
DIY builds (Tariq, 2020), and the manufacture of sanitizing tunnels (Mohamad, 2020). All of these creative ideas show that Malaysians are acting together to
battleagainst COVID-19.

Measures toovercome theeconomic downturndue toCOVID-19

In Malaysia, the massiveand ongoing outbreaks of this virus have become a seriousthreat with profound consequences for the economy and financial markets
as a whole. The financial market is predicted to collapse, with the chance of a new global recession (Majid, 2020). The sudden enforcement of the MCO by the
government put various sectors of the economy in jeopardy. According to AmBank Group chief economist Anthony Dass, direct damage caused by the virus
can be seeninthetourismandtravel industries, manufacturing, construction, mining,andagriculture, with many workers being laid offand othersbeing placed
on unpaid leave (Murugiah, 2020). The Prime Minister of Malaysia Tan Seri Muhyiddin Yassin has particularly stated that the nation's tourism industry has
been crippled, with an estimated loss of RM 3.37 billion in the first 2 months of the year (Dzulkifly, 2020). The forced closure of small businesses, mainly the
smalland mediumsized enterprises (SMEs) and services, could probablylead to permanent shutdownsand manylosing their jobs,as well as individuals going
bankrupt (Cheng,2020).
Theimpact ofCOVID-19 on the world economyasa whole has been devastating. AccordingtoTheOrganisation for EconomicCooperationandDevelopment
(OECD), the COVID-19 pandemic has led to social distress around the world, as well as huge economic disruption (OECD, 2020). The massive spread of the
virus has affected the stock markets, and the enforcement of the MCO, lockdown, and travel restrictions have significantly disrupted business activities in
various sectors, affecting people's income and causing economic chaos in the country.To minimize the economic impact of this pandemic, Malaysia has taken
severalactionsto recover the economy.
Initially, at the end of February 2020, the former Prime Minister of Malaysia, Tun Dr. Mahathir Mohamad announced a RM 20.0 billion financial stimulus
package intended to mitigate the impact of COVID-19 based on three major strategies, namely (1) lessen the effect of COVID-19, (2) people-based economic
growth,and(3) encourage qualityinvestments(TheStar,2020d).

Lessenthe effect ofCOVID-19

This strategy aimed to stimulate the travel industry, easing cash flow and providing support to affected individuals. Among the approaches by the-then
government was to ease the financial burden of the hospitality industry, giving discounts amounting to 15% off electricity bills for travel companies, airlines,
hotels, shopping malls, and exhibition and convention centres, a 6% service tax exemption for hotels from March to August 2020, Human Resource
Development Fund (HRDF) levies exemption for hotels and companies engaged in travel, reorganising of monthly payments of income tax for the vacation
industry and rental premises, landing and parking rebates by Malaysia Airport Holdings Berhad (MAHB), and giving RM 600 one-off payments to taxi
drivers, tourist bus drivers, tourist guides, and registered trishaw drivers. As a form of gratitude and appreciation, frontliners are entitled to monthly critical
allowances, for instanceRM400 for medical staffandRM200 paid monthly to immigrationandother related frontliners, to bepaiduntil this contagion ends.

People-based economy growth

Through this strategy, the minimum contribution to the Employment Provident Fund (EPF) was reduced from 11% to 7% effective from April 1, 2020 until
December 31,2020.In addition, an extra RM 100 has been paid toall the HouseholdLiving Aid recipients andRM50 will be given in the form of e-cash. In brief,
Household Living Aid isaid given by the Malaysian government to certain categories of receivers who qualify according toa set of criteria that was announced
by the government. Furthermore, an allocation of RM 40 million has been providedtoSMEs involved in food production andagriculture, RM1000 grants have
been allocated to 10,000 e-commerce entrepreneurs, and RM 20 million has been given to Malaysian Digital Economy Corporation so that rural internet
centres (Pusat Internet Desa) can be transformed into e-commerce hubs. Apart from this, the strategy has also focused on reducing the cost of living and
improvinginfrastructure, specificallyinruralareas.

Encouraging qualityinvestments

This strategy involves the exemption of import duty and sales tax for 3 years for the purchase of machinery and equipment (imported and local) for port
operations starting from April 1, 2020. Bank Negara Malaysia (BNM) is offering a SME Automation and Digitalization Facility of RM 300 million with an
interest cost of 3.75%. Another initiative under this strategy is to encourage private investment and partnerships between the public and private sectors. For
instance,the Ministry ofEnergy,Science,Technology, Environment andClimateChange willopen bids for a 1400 MW solar power generator in2020.
After the recent change in Malaysian government, an Economic Action Council was established to address various economic issues (Bernama, 2020f). This
council hasrevisitedandrevisedthe stimulus packageannouncedbytheprevious PrimeMinister,Tun Dr.Mahathir Mohamed,announcing several initiatives
aimed mainly at easing the monetary problems due to rising cases of COVID-19 and the implementation of the MCO by the government. Among the major
initiativesannouncedarethe following (Bernama,2020g):

RM500 monthly withdrawal fromtheEmployeesProvident Fund isallowed for membersaged55 years for 12 months

beginning April 1,2020;

RM 130 million allocation for all of the 13 state governments to tackle issues related to COVID-19, such as providing assistance to small business owners and
hawkers, helping COVID-19 patients
and families,as wellas frontliners;
TheNational Higher Education Fund(PTPTN) loan repayment will be postponeduntilSeptember 30,2020;and RM600 millionallocation for the MoH.

Additionally, BNM hasalsotaken somedrastic measuresto reducethefinancialimpact caused byCOVID-19 jointly withthe government. On March 24,2020,
BNM offered a moratorium or postponement of payment for all bank loans except for credit card debts. According to the Deputy Governor of BNM, Jessica
Chew,the initiative wastakenby consideringthe financial constraints of borrowers(Annuar,2020).
Table3
The PRIHATINRakyat Economic StimulusPackage (PRIHATINPackage).
PRIHATINPackage Beneficiary

RM 1 billion fund allocation to the Ministry of Health for medical equipment purchases and to pay for services, in addition to RM 500 million announced MinistryofHealth
earlier.

RM 600 allowance for healthcare personnel and RM 200 allowance to frontlinerssuch aspolice, immigration, and customspersonnel. Healthcare personnel and frontliners such as
police, immigration, and customspersonnel

RM 10 billion allocationto fund B40 and M40 familiesunder the National CaringAid (Bantuan Prihatin Nasional), including: Malaysian citizens
RM 1600 one-offpayment to 4 million householdsearningbelowRM 4000;
RM 1000 one-offpayment to 1.1 million householdsearningbetween RM 4001 and RM8000;
RM 800one-offpayment for unmarried personsaged 21 yearsearninglessthan RM 2000; RM 500 one-offpayment for 4000 singles
aged 21 yearsearningbetween RM 2000 and RM 4000.

15–50%electricitybill discount beginningon April 1, 2020 for 6 months.

Free internet fromall telcosfromApril 1, 2020 until the end ofthe MCO.
People HousingProjects(PPR) and public housingresidentsare exempted frompayingrent for 6 months.
The government allowspre-retirement withdrawal fromthe Private Retirement Scheme (PRS) of up to RM 1500 without taxpenalties.
Wage subsidyprogram for workerswho earn RM 4000 orless for 3 months.
RM 500one-offpayment for civil servantsincludingcontract staff(grade 56 andlower).
Civil servants
RM 200one-offpayment for all studentsat higher learninginstitutions. Studentsathigher learninginstitutions
RM 500one-offpayment for e-hailingdrivers. E-hailingdrivers
RM 250one-offpayment for government pensioners. Government pensioners
Buildingsbelongingto the government, such asconvenience stores, day-care centres, and school canteenswill be exempted fromrental payment. Businessowners

RM 25 million allocation in collaboration with NGOsto provide food and shelter for senior citizens, OrangAsli, and thedisabled. Senior citizens, OrangAsli, and individuals
with disabilities
National Health Protection Scheme (MySalam) and COVID-19 quarantine patientsare entitledto receive RM 50 per dayfor 14 days. COVID-19 patients

An allocationofRM 400 million toupgrade the broadband network. Telco companies

Cleaningand cateringcontract workersat schools, public universitiesand traininginstitutions, and government agencies will be paid a salaryand Contract workers(cleaningand food services)
their termsof service will be extended for another monthbytakinginto account the MCOperiod.

Insurance and takaful sectorswillprovide a special RM 8 million fund to bolsterCOVID-19 testing. Each policyholder can go for a screeningtest worth Insurance policyholders
up to RM 300 in private hospitalsandlaboratories.
TEKUN National, an agency under the Ministry of Entrepreneurial and Cooperative Development and People's Trust Council (MARA), an Small and medium-sized enterprises
agency under the Rural Development Ministry, along with other government agencies, will offer a moratorium to small and medium-sized (SMEs)
enterprisesbeginningApril 1, 2020.

Similar to PTPTNloan repayment deferment, the repayment ofthe SkillsDevelopment Fund Corporation (PTPK) loan isalso extended from April 1, PTPKloan holders
2020 to September 30, 2020.
RM 1 billion allocation for the Food SecurityFund. Food securityfund
RM, Malaysian ringgit; MCO, Movement Control Order; NGO, non-governmental organization; PTPTN, National Higher Education Fund.
On March 27, 2020, the Prime Minister Tan Sri Muhyiddin Yassin announced a new package as part of continuous efforts to reduce the effects of COVID-19.
This package is worth RM 250 billion and has been designed to safeguard the people's welfare, support businesses including SMEs, and strengthen the
economy (Yassin, 2020). The PRIHATIN Rakyat Economic Stimulus Package (PRIHATIN Package) is an addition to two economic stimulus packages
announced earlier,as mentionedabove.Table3 liststhe support andassistanceannouncedunder PRIHATIN.

Conclusions

A novel coronavirus, named SARS-CoV-2, has caused major outbreaks of COVID-19 disease with severe effects worldwide when compared to the previous
two deadly pneumonia diseases, SARS and MERS. More than 1.5 million positive cases of SARS-CoV2 infection had been recorded globally 4 months after it
was first discovered in China. At the time of writing this report, Malaysia was ranked 34th in the world based on the number of positive cases. Perceiving the
alarming trend shown in other countries, constructive actions and effective measures to overcome this pandemic became the main agenda of the Malaysian
government inthe earlystageof itsemergenceinthe country.Specific hospitalswereassignedtohandleCOVID-19 casesasa measureto isolatethe patientsand
preventthem fromaffectingothers.The capacityand capability oflaboratories were enhancedto speedup sample testing andthe provision ofresults. An MCO
was enforced asthe biggest decision bythe government to strictly and seriously break the chain ofCOVID-19 withinthe community. This tough decision has
obviously affected all sectors, especially the economy, from the smallest scope of individual income to the largest of international trade. However, all
Malaysians showed their full support of the MCO enforcement to ease the burden of frontliners, especially medical personnel, in handling the increasing
numbers of cases each day. To lessen the effects of the MCO, the Malaysian government has granted a huge budget to various sectors to lessen the effect of this
pandemic, initiate people-based economic growth, and encourage quality investments. The PRIHATIN Package has been one of the beneficial initiatives
announced by the government, followed by drastic measures of a 6-month moratorium offered by BNM to reduce the financial impact. In addition to these
collective measures,all Malaysians have played their rolethroughdifferent channelstohelp the nation in facing this major outbreak.Each individualisplaying
a big role in ensuring the communityand country become free from COVID-19. Authors’contribution
ARTICLE 2:
Malaysian role in overcoming the pandemic

Fighting against the common enemy of

COVID-19: a practice of building a
community with a shared future for
mankind
Xu Qian1*, Ran Ren2, Youfa Wang3, Yan Guo4, Jing Fang5, Zhong-Dao Wu6, Pei-Long Liu4, Tie-Ru Han7* and
Members of Steering Committee, Society of Global Health, Chinese Preventive Medicine Association

Abstract
The outbreak of coronavirus disease 2019 (COVID-19) has caused more than 80 813 confirmed cases in all
provinces of China, and 21 110 cases reported in 93 countries of six continents as of 7 March 2020 since middle
December 2019. Due to biological nature of the novel coronavirus, named severe acute respiratory syndrome
coronavirus 2 (SARS-CoV-2) with faster spreading and unknown transmission pattern, it makes us in a difficulty
position to contain the disease transmission globally. To date, we have found it is one of the greatest challenges to
human beings in fighting against COVID-19 in the history, because SARS-CoV-2 is different from SARS-CoV and
MERS-CoV in terms of biological features and transmissibility, and also found the containment strategies including
the non-pharmaceutical public health measures implemented in China are effective and successful. In order to
prevent a potential pandemic-level outbreak of COVID-19, we, as a community of shared future for mankind,
recommend for all international leaders to support preparedness in low and middle income countries especially,
take strong global interventions by using old approaches or new tools, mobilize global resources to equip hospital
facilities and supplies to protect noisome infections and to provide personal protective tools such as facemask to
general population, and quickly initiate research projects on drug and vaccine development. We also recommend
for the international community to develop better coordination, cooperation, and strong solidarity in the joint
efforts of fighting against COVID-19 spreading recommended by the joint mission report of the WHO-China
Background
A sudden outbreak of coronavirus disease 2019 (COVID-19) caused by infection with severe acute respiratory
syndrome coronavirus 2 (SARS-CoV-2) virus has happened since December 2019 in Wuhan City, Hubei
Province, a central city in the People’s Republic of China, where transportation is enormously convenient to
connecting all other places in China and overseas [1, 2]. As of 7 March, 2020, a total of 80 813 confirmed cases
reported in all provinces of China, and 21 110 cases reported in 93 countries/territories/areas of six continents [3].
In particular, some cases have been confirmed in African countries, such as Algeria, Egypt, and Nigeria [3]. This
is the biggest infectious disease outbreak in China ever since 1949, the year of founding the People’s Republic of
China. It is the biggest battle since the disease is spreading so fast with high prevalence, and the prevention of the
transmission has involved all people in the country [4]. While at global level, the strategy and coordinating
mechanism to control COVID-19 need to be set down as soon as possible [5], in particular, three questions need
to be addressed as (i) how to take the emergency response actions effectively in different countries? (ii) how to
mobilize resources quickly with strategic ways? and (iii) how to encourage people proactively and orderly to
participate in this battle against COVID-19 from different regions of the world?

Lessons from the battle against COVID-19 in China

In order to address three aforementioned questions, the lessons from China in the battle against COVID-19 need
to be understood clearly in the following three aspects:

Traditional epidemiological approaches effectively control the transmission

Professionally speaking, three steps are necessary to taken once an infectious disease outbreaks in certain regions,
including controlling infectious sources, blocking the transmission routes, and protecting the susceptive
population [6]. While, as COVID-19 spreading so fast and people’s travelling so frequent during the Chinese New
Year (Spring Festival) season, it cannot control effectively if only taking the normal or general countermeasures
[7]. Therefore, the Chinese government has quickly taken actions to contain its transmission inside China,
including detecting the disease early, diagnosis and reporting early, isolating and treatment of cases early, tracing
all possible contacts, persuading people to stay at home, and promoting social distancing measures commensurate
with the risk, etc., based on the current knowledge about epidemiological features and transmission patterns of
COVID-19.

Response strategies coping with local conditions In dealing with the outbreak, China has been adopting the way of
tailoring interventions into local settings, from quickly finding each infected person, tracing close contacts and
placing them under quarantine, to promoting basic hygiene measures to the public, such as frequent hand washing,
cancelling public gathering, closing schools, extending the Spring Festival holiday, delaying return to work, and
to the most severe measure of city lockdown of Wuhan [8, 9]. By adapting response strategies to the local context,
it may avoid blockading the city when it is not needed, and also prevent from a major outbreak without taking any
action.

Mobilizing resources quickly to support the emergency responses

Under the strong leadership of the Central Government of China, the mobilization for the emergency responses
has been effectively promoted in following ways. Firstly, a Joint Prevention and Control Mechanism of the State
Council has established involving 32 Ministries, with subgroups on control of outbreak, medical rescue, scientific
research, information and communication, international cooperation, logistics, and frontline coordination [10].
This multi-sectoral cooperation mechanism at high level is to ensure the facilities and supplies have been well
arranged to support the emergency responses in all provinces, with focus on the Hubei Province, for example,
more than 10 mobile hospitals and two big hospitals with each one having the capacity of holding more than 1000
beds have been built within 10 days. Secondly, more than 40 000 medical professionals from other provinces or
military institutions have been dispatched to Hubei Province to implement emergency responses, including
medical care and treatment, epidemiological investigations, environmental sterilization for disinfection, and data
and information management to support the policy making.

Encouraging people proactively and orderly participate in this battle against COVID-19
It is important to protect the community from exposure to the infection, all residents in the potential risk areas
were encouraged to stay at home, which is an effective way to block the transmission routes. Local community
health workers and volunteers, after the specific training, proactively participate in screening the suspicious
infections, and help in implementing proper quarantine measures by providing support services, such as driving
patients to the mobile hospitals [8]. All those activities logistically managed at the community level.
At the same time, from medical care side, the medical doctors and nurses worked very hard in the hospitals, to
screen the suspected cases, provide medical care for the confirmed cases, and taking emergency response to rescue
severe patients to reduce the fatality. While epidemiologists working in centers for disease control and preventions
provided the statistical results for the dissemination of epidemiological data correctly, and provide the well-
prepared datasets for the decision makers for coordination of necessary resources, and many health workers
investigate the suspected contactors for quick medical quarantine of the suspected cases at the community level.

Preventing the pandemic of COVID-19

With the conceptualization on building a community with a shared future for mankind proposed by Chinese
President Xi Jinping in 2013 [11], Chinese people have taken following actions to prevent the pandemic of the
diseases: (i) sharing the sequences of SARS-Cov-2 virus with the World Health Organization (WHO) and other
countries which are important information for other countries to prepare the tests for screening and diagnosis, (ii)
all epidemiological data with clinical treatment in China has been published in the international journals, (iii)
prevent spreading of the disease by traveling ban in Wuhan, (iv) medical quarantine has been performed for all
suspected contactors, (v) body temperature measuring facilities were equipped in all railway stations and airports,
etc. In order to take very strict contain measures for COVID-19 outbreak tailored to local settings, the travelling
ban was executed in Wuhan, and encouraging no gathering and less travelling in other cities out of Hubei Province.
Those actions were implemented by strong coordinating of the Chinese government in cooperation with local
residents. To date, the epidemiological data has showed more than thousands of people have been protected from
the infections, and increasing pattern of the transmission has been suppressed significantly in China [12].

Challenges in fighting against COVID-19

The fighting against COVID-19 has been lasting almost two months, and the time left for people outside of China
to prepare the countermeasures has been narrowed quickly. To date, we have found it is one of the greatest
challenges to human beings in fighting against COVID-19 in the history, since the pathogen of SARSCoV-2 is a
new coronavirus, differed from either SARSCoV or MERS-CoV in terms of biological characteristics and
transmissibility [13].
Technically, we have little knowledge on the pathogen and pathogenesis, without specific effectively drugs or
vaccine against the virus infection, which cause difficulties in rescuing the severe cases which account for about
20% of the infections. The transmission routes are not clear enough, although we currently understand that the
respiratory transmission from human to human is the major transmission route, but other ways for transmission,
such as gastrointenstinal transmission or aerosol propagation, is not so clear.
Administratively, implementing the locked down measures in such a big city with over 15 millions of people is
not an easy task, with a lot of preparing works from different dimensions of municipal logistic management, to
support the emergency response actions. Thus, the multiadministrative systems need to be coordinated
collectively, guiding from the central government, with more resources gathering from various places all over the
country.
Globally, the information sharing is so important, including patients’ information sharing to trace the suspected
cases to protect more people as quickly as possible, genome sequences information sharing to prepare the
diagnostics as quickly as possible, and treatment schemes sharing to rescue more severe cases. The WHO declared
the Public Health Emergency of International Concern based on the International Health Regulation (2005) in the
early time of the outbreak of COVID-19, as it is an extraordinary event to constitute a public health risk to the
states through the international spread of disease, and to potentially require a coordinate international response
[14]. All actions to strengthen surveillance and response systems on infectious diseases need to put emphasis on
resources limited countries, such as Southeast Asia and African countries [15].

Recommendations
With understanding more about the nature of COVID19, it is necessary to understand clearly the current challenges
against COVID-19 become increasing, not only to China but also to the world. In order to take quick actions to
early prepare the battle against COVID-19 and better allocate enough health resources from the world, the
recommendations are as follows:

Coordinating interventions and resources mobilization globally

Preparedness in low and middle income countries WHO has identified 13 African countries at the top-risk affected by
COVID-19 but with limited resources against COVID-19, including Algeria, Angola, Cote d’Ivoire, the
Democratic Republic of the Congo, Ethiopia, Ghana, Kenya, Mauritius, Nigeria, South Africa, Tanzania, Uganda
and Zambia. These countries have direct links or greater numbers of people travelling to/from China [15]. The
preparing works on response to the imported cases need initiated as soon as possible with the assistance of WHO
as well as developed world. The major preparing works are to prepare enough facilities for use in hospitals, such
as test kits, facemasks, and personal protective equipment (PPE), to prepare the quarantine measures in each gate
of the traveling venues, and to prepare information communication, etc. The emergency response mechanism on
multi-sectoral cooperation needs to be established once the first case has been detected.

Intervention and coordination globally

The fast spreading of COVID-19 to more than 90 countries/territories, with some cluster cases occurred in a few
countries, demonstrated that this new disease has higher transmissibility compared with SARS and MERS. The
nature of high transmissibility for COVID-19 requires us to (i) prepare the battle globally as soon as possible, by
taking the advantage of the time window opened by Chinese battle against COVID-19, (ii) invest more weapons
or tools against the diseases by better global coordination, and (iii) take proper quarantine measures globally [16].
We are able to win the battle only if our actions are coordinated better at a global level.

Resources mobilization globally

One of lessons learnt from the battle in Wuhan is the speed of resources gathering against COVID-19 outbreak
could not catch up the speed of the coronavirus spreading in early stage of the outbreak, and it is in need of support
or assistances from outside of epicenter, including medical doctors, nurses, and facilities of PPE used in hospitals,
and facemasks for residents. The strong support from outside of epicenter quickly to ensure all infectious sources
either controlled through quarantine measures or treated in the specialized hospitals. Therefore, for those countries
with weak health system, it is so urgent to get help from other parts of the world. WHO needs to mobilize its
certified global emergency medical teams to get ready to be dispatched to other countries where health workers
are in short supply while an outbreak occurs.

Jointly fighting against common enemy ─ COVID-19

As said by WHO Director-General in the news press on Public Health Emergency of International Concern
declaration that “this declaration is not a vote of no confidence in China, our greatest concern is the potential for
the virus to spread to countries with weaker health systems.” Therefore, international community needs to work
together to prepare for the containment of COVID-19 transmission and spreading in other countries, under the
scenario that more countries may be affected by the new coronavirus [17]. These containment works have to
quickly take readiness on active surveillance, early detection, isolation and case management, contact tracing and
prevention of onward spread of COVID-19.
Therefore, at this stage, with more countries having confirmed more and more COVID-19 cases, all countries
need work together on the following global actions on:

(i) fighting against COVID-19 spreading, includingsharing the information of the disease transmission and
epidemiological knowledge, sharing the experiences on case management and treatment approaches both
for severe cases or light symptoms, and sharing new technologies or strategies to contain the transmission;
(ii) fighting against violating International HealthRegulation, by following the WHO’s authoritative advices
which called on all countries to implement decisions that are evidence-based and convincing. We need to
improve our quarantine measures to replace the disconnection of international traveling and trade
restrictions, with an assistance of the improved active surveillance systems and AI-based technology to trace
the contactors;
(iii)fighting against stigmatization, since the stigmatization is always present when the disease outbreak and
people facing the sudden attack of this kind of epidemic. These phenomena on stigmatization may be at a
scale of epicenter areas, or may be at a country and regional scale, and even at global scale. Thus, we need
fight with the real and common enemy which is the new coronavirus, rather than the infected people. The
international community needs the solidarity and sympathy to start the battle against the common enemy –
the new coronavirus, as well as against stigmatization at the same time.

Global cooperation in priority settings

By considering COVID-19 is spreading so fast which causes difficulties in containing the disease, we, as a
community of shared future for mankind, need better coordination in global cooperation and further improvement
in the multi-sectoral cooperation in order to quickly take response and prevent from the pandemic [18]. In addition,
we also need better coherence of our resources with more international partners, at least, we can quickly improve
our priority settings in sharing information and data, on research priority settings, on surveillance and response to
outbreaks at a global level.

Cooperation on sharing information and data

In order to quickly share the information and datasets for countermeasures, the actions on fast and open reporting
of outbreak data and sharing of virus samples, genetic information, and research results are encouraged for all
international communities, non-governmental organizations (NGOs), as well as governmental institutions around
the world. Through regional and country office of WHO, more preventive information against COVID-19 can be
disseminated to the public in the vulnerable countries.

Coordination on surveillance and response

With understanding the importance of human health in the planet, multi-sectoral and multi-lateral cooperation
against COVID-19 pandemic are recommended at global level. Particularly, the scientific communities,
governments and NGOs in different fields, such as public health, agriculture, ecology, epidemiology, governance
planning, science, and many others need to collaboratively prevent future outbreaks, with better coordination. The
secretary of the United Nations need take the responsibility to coordinate the actions on protecting the planetary
health by systematic approaches, such as EcoHealth, One Health, Planetary Health and Urban Health, and making
sure public resources are worthwhile investing in strengthening surveillance and response systems for preventing
future outbreaks of emerging infectious diseases.

Coherence on research priority settings

We urgently encourage all governments and international foundation to support short-term and emergency
response-related research projects to improve our understanding of the causes, risks, infectiousness, and threats of
a pandemic [19]. Health institutions at international level should be encouraged to organize the research priority
settings on preventing the pandemic or averting the emergence of the disease. International conservation
organizations start to take investigations on types of wildlife-pathogens interactions affecting human health.
International environmental agencies can initiate researches on unsustainable transformations of natural
environments and ecosystems that provide lifesupporting services for our health.

Conclusions
To summarize, COVID-19 is a new disease that has caused great impacts to the people’s daily life
extraordinarily. We, as a community of shared future for mankind, need to take collectively and quickly strong
emergency responses as a battle against our common enemy, the new coronavirus, not only in China but also in
the world. All partners of international community and country leaders are encouraged to proactively take
strategic actions as soon as possible to fight the COVID-19 together. Hard times will end finally, and we will
meet each other in the blooming spring soon
ARTICLE 3:
Malaysian role in overcoming the pandemic
MALAYSIA’S APPROACH IN HANDLING COVID-19 ONSLAUGHT:
REPORT ON THE MOVEMENT CONTROL ORDER (MCO) AND
TARGETED SCREENING TO REDUCE COMMUNITY INFECTION RATE
AND IMPACT ON PUBLIC HEALTH AND ECONOMY

Noor Azah Aziz*(NA Aziz)1, Jamal Othman (Othman J)2, Halyna Lugova (H
Lugova)3, Adlina Suleiman (Suleiman, A)4
On behalf of the Economy and Social Wellbeing Cluster, Academy of Professors
Malaysia (APM) and Ministry of Health, Malaysia
1
Department of Family Medicine, Medical Faculty, UKM Medical Centre (UKM MC), Cheras, Kuala

Lumpur, 53100, Malaysia.

2
Malaysian Institute of Economic Research (MIER), JKR 606, Jalan Bukit Petaling, 50400, Kuala

Lumpur Malaysia
3 4
National Defence University Malaysia, Kem Perdana Sungai Besi, 57000 Kuala Lumpur Malaysia
International Medical University, Bukit Jalil, 57000 Kuala Lumpur Malaysia

Summary:

Malaysia recorded its first case of COVID-19 on January 24th, 2020 with a stable number of
reported cases until March 2020, where there was an exponential spike due to a massive
religious gathering in Kuala Lumpur. This caused Malaysia to be the hardest hit COVID-19
country in South East Asia at the time. In order to curb the transmission and better managed
the clusters, Malaysia imposed the Movement Control Order (MCO) which is now in its
fourth phase. The MCO together with targeted screening have slowed the spread of COVID-
19 epidemic. The government has also provided three economic stimulus packages in order to
cushion the impact of the shrinking economy. Nonetheless, early studies have shown that the
MCO would greatly affect the lower and medium income groups, together with small and
medium businesses.

(138 words)

Keywords: COVID-19, Malaysia, Movement Control Order, economic impact Malaysia’s

Approach in Handling COVID-19 Onslaught: Report on the
Movement Control Order (MCO) and Targeted Screening to reduce Community
Infection Rate and Impact on Public Health and Economy

Introduction:

The COVID-19 virus first emerged in Wuhan, China in late December 2019, and presented
initially as pneumonia of an unknown cause amongst traders and visitors to
Wuhan’s seafood market which was also selling exotic wild animals (1). From a zoonotic
transmission, the virus has evolved into a person-to-person transmission, with a widening
clinical spectrum from asymptomatic infection to respiratory tract spectrums and even death
(2). This alerted the international community and since then the disease has spread
worldwide, involving more than 180 countries forcing the World Health Organization
(WHO) to declare COVID-19 as a pandemic on March
12th, 2020 (3). Malaysia recorded its first case on January 24 th, 2020 and up until March 2020,
case numbers remained relatively low and occurred mainly among foreign arrivals from
China (4). Nonetheless, Malaysia had its first large daily spike on March 15 th, 2020 with 190
cases, most of them being linked to a massive religious event in Kuala Lumpur. The
following day (March 16th, 2020) the cumulative cases had surpassed the 500th mark with the
first COVID-19 death reported on 17th March, 2020 (Figure 1) (4). Due to the rapid increase
in positive cases and the difficulty in tracing the contacts, the government of Malaysia has
imposed the Movement Control Order (MCO) on the 18th March 2020.(5)

A: The implementation of the MCO – the early challenges

Following the implementation of the MCO, all Malaysians were instructed primarily to stay
indoors. Other restrictions imposed included prohibition of mass gatherings, health screening
and quarantine for Malaysians coming from abroad, restriction on foreigners entering the
country and closure of all facilities except primary and essential services such as health
services, water, electricity, telecommunication and food supply companies (6) .

The early management of COVID-19 in Malaysia, prior to the MCO, was challenging.
Initially, the reporting of COVID-19 was classified as an influenza infection due to the
concurrent winter season in the northern hemisphere countries together with the movement of
people during the end of year holiday season. Based on this presumption, although initial
precautions had been implemented by the Ministry of Health, earlier actions identified people
who were at risk and those with influenza like illness to be screened and further managed.
Due to the novel characteristics of the virus, many countries including Malaysia had assumed
that the COVID-19 infection could be a local outbreak whereby chances of the spread to
other countries were slim (7). Many countries had initially downplayed the severity of the
virus as there was a lack of understanding of the characteristics of transmission (6). In
addition, during the first phase of the outbreak, Malaysia encountered a unique situation
where a sudden change of government left the country with a void in good governance. The
management of the outbreak was entrusted to the Ministry of Health (MOH) alone; without
cohesive management by other government agencies. During this interim phase, the COVID-
19 outbreak was managed by the civil servants of the MOH, which is known for its tightly
knit professional core that is independent of politics, headed by the highly capable Director
General of Health who was voted one of the top three medical doctors in the world in
handling the COVID-19 crisis (8,9). Although the medical fraternity in Malaysia is diverse in
their provision of service, they share a common thread that is set by professional and medical
ethics, and follow adherence to evidence-based medicine in delivery of medical care and
public health services.

At the early stage of the outbreak, East Asian countries had already experienced a surge of
positive cases which had prompted the respective governments to impose stricter public
health measures. This included movement restrictions, social distancing and banning of mass
gatherings (10). On the other hand, until the declaration of the pandemic by the WHO on the
12th March, 2020, many countries including Malaysia were managing the infection in a less
aggressive manner. These countries had kept their borders open to visitors with a lack of
screening at entry points and had left those with infected status to enter freely into the
country. This in turn created a sense of insecurity among the public.

As a result, Malaysia faced two different COVID-19 clusters within a short period of time,
the first being from imported cases and the latter from the religious mass gathering involving
several thousand participants from more than 15 different countries. Due to the exponential
spike in the COVID-19 positive cases, the state of MCO was declared on March 16 th, 2020 to
commence on March 18th, 2020 (10).
B: Flattening the curve – the Malaysian initiative

Whilst Malaysia’s decision to implement the MCO was slightly later compared to other
affected countries such as South Korea, the result of this implementation had surprised many.
Earlier in March, JP Morgan Chase & Co together with Malaysia Institute of Economic
Research (MIER) (11) predicted that Malaysia will have an acceleration of cases that would
peak mid-April, with between 6000 and 8500 cumulative infections.

With the concurrent onset of the COVID-19 clusters, the government needed drastic
interventions to prevent the prediction from becoming a reality. The approach taken by
Malaysia had been based on past experiences from China and South Korea.
China’s drastic measure of controlling the spread of the virus in Wuhan had showed
resounding success after more than 70 days of a strictly controlled, tight lockdown.
Nonetheless, this may not have been a suitable option for Malaysia (12). The nature of
Malaysians who are more sociable and have the affinity for social gatherings might pose as a
difficult challenge should the complete lockdown be imposed. On the other hand, South
Korea had used a different approach. The South Korean model relied heavily on two
approaches: mass screening to detect and treat positive cases and strong nationwide IT
coverage to trace and inform the public of the COVID-19 progress (13),(14). Although the
South Korean model appeared to be more suitable, the issues of constrained resources and
limited IT coverage in rural areas made it a challenge should it be implemented in Malaysia.

Hence, the MOH and the government designed a combination of MCO measures and targeted
screening approaches to be used during the mitigation phase. This was to create a small
window of opportunity aiming to break the transmission chain of the virus. Firstly, the
government’s implementation of the MCO in restricting mass movement was aiming to
achieve two objectives: slowing the transmission chain in the community and allowing the
MOH to trace, isolate and manage the identified positive cases. Secondly, with the restricted
movement measures in place, the MOH would be able to fully screen and manage the
existing clusters as to prevent the transmission from extending beyond the first or second
generation of infection. In order to accomplish this within the incubation period time frame
(0-14 days post exposure), collaborative approaches between the sectors were used. These
included the health sector, police, military, academicians, statisticians and others to work
together in curbing the transmission. Each of these sectors worked differently but ultimately
towards the same goal. For example, whilst the health sector was responsible for managing
the medical and public health aspects of the infection, the police and military worked closely
together to enforce the movement restriction orders, especially in the red zone areas. As
COVID-19 situation changes frequently, standardised operating procedures (SOP) were
needed for the references of the health care workers and the public. Hence, the academics and
statisticians often worked hand in hand with the government, in advising and providing data
in managing the pandemic in Malaysia.

Thirdly, an aggressive screening approach has been used to isolate and treat positive cases.
These include identifying at risk individuals within the identified clusters, screening the
contact and close contact individuals to the positive cases, and also door-to-door screening
exercises in red-zone areas. Although Malaysia has yet to reach the target of 16,500 tests
daily (currently 11,500 tests are conducted daily, 69.7% coverage), the current testing is able
to detect and identify a significant percentage of positive cases per population (7.2% of the
positive rate vs. the WHO standard of 10.0% of the positive rate) which is at par with the
current WHO standards (15). The expansion of the number of laboratories from 4 to 48
laboratories nationwide has enabled the testing to be done more quickly and within the
targeted time-frame. Fourthly, using mass media and IT technology, the government has been
able to reach a wider public coverage and within a shorter period of time. The dissemination
of information includes the following: regular media announcements from the MOH
regarding social distancing, hand washing and inviting contacts from the religious cluster to
come forward for testing, daily personal texting to individual’s smartphones of government’s
directives and advice, and also daily countering of COVID-19’s fake news as to prevent
confusion and panic amongst the public. In addition, daily media press conferences by the
same authorities (Director of Health and The Minister of Defence) has created a sense of
security and confidence among the public during the period of this pandemic.

This, together with aggressive intervention in the managing of COVID-19 cases in hospitals
using methods of strict surveillance for the positive cases, early intervention in symptomatic
cases and a combination drug therapies have shown a dramatic improvement in the recovery
rate, starting from Day-7 after the start of MCO-1 or the 17th day after the hundredth case
(Figure 2). Up until the 9th of April, 2020, Malaysia had reported a recovery rate of 38% with
a fatality rate of 1.58% (15). In terms of early intervention in symptomatic cases, Malaysia
has adopted the clinical staging in identifying those who are at risk of respiratory
deterioration by instituting a combination of drug therapies. There are five clinical stages:
asymptomatic (stage 1), symptomatic but without pneumonia (stage 2), symptomatic with
pneumonia (stage 3), symptomatic, pneumonia and requiring supplemental oxygen (stage 4)
and critically ill with multi-organ failure (stage 5). Several warning signs include fever,
tachycardia, dropping of ALC and an increase in CRP levels which may denote deterioration
in general well-being, even though patients are still in stage 1 and stage 2 (16). In terms of
combination drug therapies, until now there is still no specific treatment for the COVID-19
infection that is currently approved with limited data on experimental agents including
chloroquine, hydroxychloroquine, lopinavir-ritonavir, interferon, ribavirin etc, as the situation
is dynamic and-changing daily (16). Up to recently, patients were given a combination of
drugs based on clinical staging and the patient’s clinical condition.

Looking into Figure 3 (17), the rise of daily cases from the 3 rd of March, 2020 (peak 2) to the
15th of March, 2020 (peak 3) followed closely the predictive trajectory with cases remaining
in an upward trend. The actual cumulative confirmed cases as compared to projected
cumulative confirmed cases remained the same until 23rd March 2020, with projected cases
predicted to have an exponential peak from 30th
March onwards. The first phase of MCO (MCO-1) of a 14 days’ duration (from the 18th of
March to to the 31st of March, 2020) started to show a small gap between actual and projected
cumulative cases. Nevertheless, the day to day cases remained unstable. The results of the
second phase of the 14-day MCO (commenced April 1st) showed interesting findings. Up to
8th April 2020, the actual reported cases were lower compared with the projected baseline
trajectory (5.11% vs. 7.44%). Although there was a promising sign that the daily cases were
beginning to indicate a downwards trend, the overall trend remained unstable, with cases
fluctuating day to day, and small peaks in between. Even 24 days after the implementation of
the MCO (April 11, 2020), the desired effect of flattening the cumulative case curve
remained elusive. Although the MCO-1 and MCO-2 have by far successfully suppressed
approximately 6352 cases (58% of the total projected cases without the MCO scenario as of
April 11), it had yet to reach the inflexion point, which typically denotes the start of a
sustained diminishing rate of increases in cases. This compares to South Korea where the
inflexion point for total cases was achieved 17 days after the hundredth case. As a result, on
the 10th of April, the government announced a third MCO extension (MCO-3) for another 14
days (from the 15th of April to the 28th of April, 2020) followed by a fourth MCO (MCO-4)
extension (29th of April 2020 to 15th of May 2020) with the aim to further widen the window
of opportunity to flatten the curve and deny the baseline projection.. From Figure 3, the
COVID-19 cases in Malaysia showed two interesting findings. Firstly, the overall cumulative
actual cases trajectory (presented in blue line) appeared to push the active cases curve
upwards, but it was markedly lower than the projected baseline trajectory. The effect of the
MCO in flattening the curve can be seen from the mid MCO-3, with relatively lower trend in
MCO-4 and further. This prompted the government to start the Conditional Movement
Control Order (CMCO-3 and CMCO-4) from 13th of May 2020 to 9th of June 2020. The
CMCO has eased some of the strict restrictions imposed to the public and reopening the
national economy in a controlled manner. However, when benchmarked to South Korea, the
normalized cases show considerable weakening of relative performance, possibly due to the
increased number of testing in recent weeks and spikes attributed to foreign workers.

Secondly, with regards to the actual active cases (presented in blue dotted line), the data
suggests that active cases may have reached their peak on April the 6th, the 28th day after the
100th case or the 18th day after the start of the first MCO. From April the 11 th, the MCOs
seem to show an effect to reduce the active cases. However, it lags from South Korean’s
benchmark model by seven days. Malaysia’s four MCO series followed by two CMCOs have
worked very well, as reflected especially by the relatively stable and low number of active
cases during the CMCO period. Figure 4 illustrates the actual number of COVID-19 cases in
Malaysia in terms of cumulative and active cases. There is an apparent gap between the
cumulative cases, which stood at 8000 cases at the end of CMCO period and the number of
active cases with the risk of infectivity ranging from 1200 to 1500 cases towards the end of
the CMCO period. This widening gap proved that the moves in restricting the public
movement together with targeted mass screening approach and early intervention were able
to curb the surge of COVID-19 infection in Malaysia.

C: The impact of MCO to nation’s health and economy

The tailor-made combination of movement restriction orders and the aggressive screening
exercises have given the much needed hope to Malaysia in fighting the COVID-19 pandemic.
While the flattening curve effect and the turn-around inflexion point remain elusive with a
possibility of emerging of a new cluster among the population, there is an early sign that this
combined approach is appropriate for Malaysia. Admittedly, prolonging the MCO is not
without its adverse implications.

The impact on public health

Most of the legal procedures on infection disease prevention and control is documented in
Act 342 Prevention and Control of Infectious Diseases Act 1988 under the Laws of Malaysia
(16). The MOH Malaysia has also issued COVID-19 guidelines in its portal (17) which
follow recommendations of the WHO interim guidance on infection prevention and control
during health care when the COVID-19 is suspected.

The first requirement in any epidemic would be crisis procurement of healthcare equipment
such as test kits, personal protective equipment (PPE) and ventilators. According to the
WHO Scientific Brief (2020) of the current evidence, the COVID-19 virus is primarily
transmitted between people through respiratory droplets and contact routes. Airborne
transmission may be possible in specific circumstances and settings in which procedures or
support treatments that generate aerosols are performed: endotracheal intubation,
bronchoscopy, open suctioning, administration of nebulized treatment, manual ventilation
before intubation, turning the patient to the prone position, disconnecting the patient from the
ventilator, non-invasive positive-pressure ventilation, tracheostomy, and cardiopulmonary
resuscitation.
..

The guidelines (17) have recommended airborne precautions (using PPE) when handling
suspected infected persons during procedures and support treatments that generate aerosol.
The difficulty is that demand for the equipment exceeds its supply. The test kits and
ventilators would have to be procured from overseas. Initially there was concern that the
current stock of PPE would be insufficient to meet the expected demand but Malaysians have
risen to the occasion in a unique show of support and solidarity by either directly producing
the PPE or donating towards the manufacture or procurement of PPE. From within
healthcare facilities to private conglomerates through non-governmental organizations, prison
and orphanages, many have contributed to this endeavour, regardless of race, religion or
social standing (18,19, 20, 21).

The second requirement is to test as many as possible since the testing of all is not financially
feasible or logistically possible. In this aspect, the MOH has purchased high accuracy rapid
test kits from South Korea and is able to conduct about 22,000 tests per day. The current RT-
PCR test whilst highly accurate with specificity and sensitivity rates of 90 percent and above,
takes 2 to 3 days to obtain the results and is relatively expensive (MYR 380 – 700/test, USD
89 – 163/ test). Until May the 25th, 2020 a total of 513,370 tests have been conducted of
which 7417(1.45%) were positive (22). Malaysia is doing a targeted screening approach, by
which areas with COVID-19 infections are categorized as red zone (high infectivity), orange
(moderate infectivity) and green (low infectivity). Of the red zones areas, further enhanced
MCO is implemented as to do door-to-door screening and testing.

Thirdly, to prevent infection from outside Malaysia, all overseas inbound passengers are
quarantined for 14 days. The Defence Minister Datuk Seri Ismail Sabri Yaakob made an
announcement on April the 2nd, that the compulsory 14-day quarantine order for all
Malaysians and visitors returning from overseas would start on April the 3rd, 2020. All
returning Malaysians or foreign visitors who enter the country are subjected to the quarantine
procedure at all entry points, irrespective if they travelled by air, sea or land (23). Malaysia
has identified 409 quarantine centres across the country, that once opened could
accommodate over 40,000 people at the same time. As at April the 4 th 2020, a total of 1,188
Malaysians who returned from abroad had been quarantined (24). All symptomatic COVID-
19 positive persons have been isolated in hospitals and quarantine centres. Unfortunately,
Malaysia has not been able to identify asymptomatic positive cases, except a few who were in
contact with the positive cases, due to lack of rapid testing. This creates a lag between
identified cases and potential contacts, resulting in further spread of infection in the
community (25, 26).

Impact on economy

The Malaysian government, over a span of six weeks, has announced three economic
stimulus packages with a total value of MYR260 billion (USD 60 billion), representing some
17% of the country’s GDP. It mainly comprises loan deferments, loan guarantees, one-off
cash assistance, credit facilities and rebates as well as a direct fiscal injection of
MYR35billion (USD 8 billion) (27, 28). The bulk of this package targeted the lower and
middle income groups, followed by assistance to small and medium enterprises which
contribute 66% to employment and 38% to the country’s GDP. The aim is to alleviate
difficulties faced by people in the lower income group who are bound to face severe
disruptions to livelihoods during the MCO period.

The Malaysian Institute of Economic Research’s forecast shows that in the absence of strong
economic stimulus, Malaysia’s real GDP may shrink by about 2.9% in 2020 compared with
2019, resulting in an estimated 2.4 million people losing their jobs. Of these, 67% will be
non-salaried, unskilled workers (26). Kochar and Barroso’s (2020) report for the U.S. also
found that most workers that are at higher risk of job loss due to COVID-19 are the low-wage
workers. Among the 19.3 million American workers aged 16 to 24, 9.2 million (or almost
50%) are employed in the services-sector, which face a greater likelihood of closure.
Therefore, the young people working in this sector are disproportionately affected by layoffs
related to the COVID-19 pandemic. The situation may not be much different in Malaysia.
Recently, the Academy of Professors Malaysia (APM) conducted a study on some 900 online
respondents and found that 91% were able to sustain themselves for the first two weeks of
MCO (ending 31 March). However, only 58% would be able to sustain themselves if the
MCO was extended by another two weeks (to 14th April). About 43% were fearful of losing
their jobs, mainly among the young age groups of 18 to 37. Whilst the economic stimulus
may be able to provide some relief to households and businesses, many are concerned about
the bleak reality and uncertainties of COVID-19 and its impact should the MCO be extended
further. Many economists are now calling for the government to identify optimal control
measures that weigh the health benefits of control against its overall economic costs.

D: The way forward and conclusion

At the time of writing (26 May), Malaysians are in phase 4 of the MCO which is scheduled
to end on 9th of June, 2020. This phase, known as the conditional movement control order
(CMCO), allows certain businesses to open and a more relaxed movement of people with
mandatory standard operating procedures, such as temperature checks, wearing of face
masks, social distancing of two metres, use of hand sanitizers regularly, no mass gatherings,
registering names and hand-phone numbers at each premise visited.
There is a change in the profile of people detected positive in Malaysia since early May. By
the 10th of May, 2020, it was evident that new clusters had emerged among foreign nationals,
making up between 70% to 80% of new COVID-19 cases (29). By the 21st of May, 2020,
new clusters of infection were detected among illegal foreign workers at immigration
detention centres initially in Bukit Jalil (35 non-Malaysian cases), followed by 21 cases
among foreign detainees in Sepang on the 23rd of May and followed by a further 27 cases in
Semenyih on the 24th of May (30). During the Eid celebration speech on the 23 rd of May, the
Prime Minister Tan Sri Muhyiddin Yassin informed the public that any decision to end the
CMCO would depend on how far the people can conform to the Government’s standard
operating procedures and apply them as part of daily life in order to stop the spread of
COVID-19. He implied that an exit plan for the MCO was in the works while urging
community leaders to take charge in helping to break the transmission of COVID-19 (31).

Prior to the Prime Minister’s announcement, an article was published in Kolumnis Awani
(local news channel) on the 13th of May with reference to community empowerment which
contained the following suggestions for community leaders:
1. To follow SOP’s laid out by the Ministry of Health, National Security Council and
Prime Ministers Department
2. To take charge of individual and community health prevention activities 3. To
stop the community misinterpretation of messages or instructions that are announced by
the government
4. To establish a community system that works with the government (local or federal) in
managing COVID-19 in the community including using existing community committees in
keeping the community safe, working with age-specific groups in reaching out to ‘at risk’
individuals or ‘in-need’ families and activating neighbourhood watch to keep track of the
communities’ well-being.
5. To monitor the mental stability of households and the community and assist in getting
help for those suffering from mental issues for example depression and anxiety
6. To be aware of any community members needing basic needs for example food packs,
medical aid and be able to deal with the needs
On June 7, 2020, Prime Minister Tan Sri Muhyiddin Yassin announced that the Conditional
Movement Control Order (CMCO) would end June 9, 2020 and be replaced with the
Recovery Movement Control Order (RMCO). The government eased restrictions under the
condition that the public take responsibility in adhering to the SOPs that have been set.
Community leaders, NGO leaders and employers must empower the people to work together
to break the chain of the COVID-19 virus transmission and comply with SOPs (34).

The tailor-made in phases MCO and the aggressive screening method appear to show clear
signs of slowing down the infection among the local population but the number of positive
cases are rising again due to transmission among foreign workers and imported cases from
Malaysians returning from abroad. The challenge now is to contain the infection among the
illegal foreign workers in the country who will have to be identified, tested, treated and
repatriated. The local spread has to be contained by educating the public to be more socially
responsible and self-disciplined. The uncertainty of COVID-19 is now reaching beyond
health impact, outreaching to economic and livelihood implications of this country and it can
only be overcome by good communication, clear and transparent clear information flow as well as
cooperation between the people of Malaysia and the authorities.
ARTICLE 4:
Malaysian role in overcoming the pandemic
Sharing Information on COVID-19: the ethical challenges in the
Malaysian setting
Aimi Nadia Mohd Yusof1 & Muhamad Zaid Muuti1 & Lydia Aiseah Ariffin1 &
Mark Kiak Min Tan1

Received: 28 April 2020 /Revised: 1 June 2020 /Accepted: 2 June 2020 /

Published online: 25 June 2020
# National University of Singapore and Springer Nature Singapore Pte Ltd. 2020

Abstract
The COVID-19 pandemic has raised challenges in dealing with information sharing by the public and the
authorities. There are two categories of information sharing on social media that are believed to be potentially
problematic and unethical: the sharing of personal information of patients and the sharing of fake news or false
information. We present a discussion on how the response to the COVID-19 pandemic in Malaysia can be ethically
handled in terms of information sharing. It is recommended that the public should cultivate the basic skills to
evaluate information and determine its validity. On the other hand, the authorities should refrain from placing the
blame on patients to avoid them from being stigmatized. It is crucial that all parties are aware of their ethical duty
to ensure only ethical and valid information gets shared on social media.

Keywords COVID-19.Pandemic.Publicinterest.Informationsharing.Confidentiality.
Privacy

Introduction

The current coronavirus disease 2019 (COVID-19) pandemic caused by the severe acute respiratory syndrome
coronavirus 2 (SARS-CoV-2) has resulted in an international public health emergency and created unprecedented
ethical challenges towards the response in handling the situation. The short history of COVID-19 began in
December 2019 with reports of patients with pneumonia of unknown aetiology being

* Aimi Nadia Mohd Yusof aiminadia@uitm.edu.my

1
Medical Ethics and Law Unit, Faculty of Medicine, Universiti Teknologi MARA, Selangor, Malaysia

diagnosed in China, which quickly turned into an outbreak (BBC News 2020). While Chinese officials declared a
lockdown of Wuhan on 23 January 2020, this failed to deter the spread of the virus around the world. The World
Health Organization (WHO) declared the COVID-19 outbreak to be a Public Health Emergency of International
Concern (PHEIC) on 30 January 2020, and subsequently a pandemic on 11 March 2020 (WHO 2020a).
Cases have increased exponentially since the initial detection of this disease involving more than 185 countries
and territories worldwide (WHO 2020a). More than 1.6 million cases were confirmed with over 100,000 deaths
by mid-April 2020 and this tally surpassed 5 million cases cumulatively with over 300,000 deaths by mid-May
2020 (WHO 2020a). Lockdowns and various other public health measures that encourage social distancing have
been implemented in many countries in the attempt to ‘flatten the curve’. Malaysia and its neighbouring countries
have also not been spared this ordeal.
 It is never easy facing the unknown, and amid the fear in the midst of this pandemic with a novel virus, there
have been a host of different reactions. For governments, there has been a need to balance between containing the
problem in the name of public health and the performance of the economy. There is also a need to ensure that
excessive anxiety and subsequent panic are not induced by the irresponsible spread of fake news. On a societal
level, this can cause a loss of confidence in the government’s decisions and policies on how it handles the
pandemic, economic recessions, retrenchments and unemployment (Greenberg and Rosner 2020). On an
individual level, this may cause panic buying and hoarding (Lai 2020), psychological distress (Ministry of Health
Malaysia 2020a) and instil fear among certain groups within the population.
In Malaysia and many other affected countries, we believe that there are two problematic categories of
information sharing on social media that worsen the situation. Firstly, the sharing of personal information of
patients and their families by the public, the authorities or third parties, and secondly, the sharing of fake news or
false information. The sharing of personal information raises the risk of stigmatization, discrimination and blame.
There is an increased risk that the public may start blaming patients with COVID-19 openly for initiating clusters
of infection, and indeed, in some cases, these patients have had to respond openly to such allegations to defend
themselves (Atan 2020; Sukumaran 2020). The sharing of false information is not unique particularly for this
pandemic, but the impact is causing the public to be anxious and fearful (Ortutay and Klepper 2020; de la Garza
2020).
In this paper, we discuss how the response to the COVID-19 pandemic in Malaysia with regard to information
sharing can be ethically handled. This includes understanding the difference between information that is disclosed
in the interest of the public and information that is interesting to the public. This understanding is essential in
determining information that is ethical to be published publicly for reading and sharing. We will examine the two
problematic categories of information sharing and how the public and the authorities should react responsibly in
handling them. We will also provide some recommendations on how the public can determine information validity
during this pandemic.
The problems

The sharing of personal information of patients

Since the beginning of the COVID-19 pandemic, Malaysians have witnessed a series of patients’ personal
information being leaked into social media. For instance, a patient known as ‘Patient 16’ had become a target of
hate and discrimination after his name and profile picture were widely circulated on social media, which continued
even after he was cleared of the virus (The Star 2020b). In other cases, the sharing of personal information
regarding ‘Patient 26’ and ‘Patient 136’, who were alleged to be ‘superspreaders’, have necessitated them to defend
themselves publicly on social media (Atan 2020; Sukumaran 2020). Unfortunately, their actions resulted in further
criticisms being made towards them. These three examples illustrate that the protection of patients’ privacy in a
pandemic is a critical step in deterring stigmatization, discrimination and blame.

The sharing of fake news or false information

Information related to this new pandemic transmits very rapidly online. While the virtually instantaneous
dissemination of information may be helpful in some circumstances, verifying the accuracy of the disseminated
information can be potentially problematic causing an ‘infodemic’ (Zarocostas 2020). The WHO defines an
‘infodemic’ as an excessive amount of information which consist of some inaccuracies that cause difficulties for
the public to obtain reliable information and dependable advice when they require it (WHO 2020b). The problem
with spreading unverified information occurs when irresponsible citizens share fake news or false information
around. This has the potential to expose unsuspecting members of the public to being deceived that information
is true. This is morally unacceptable, especially when the spread of such information is shared intentionally to
deceive others.
Fake news is composed of intentionally misleading news that may not be entirely wrong with the aim to
influence views (Kanekar and Thombre 2019). On the other hand, false information, which is a subcategory under
the broad wings of fake news, consists of intentionally fabricated stories that are routinely generated to publicize
certain agenda (Molina et al. 2019). Infodemic results in making efforts to contain the pandemic more complicated
due to the effects of publicizing needless alarm and uncertainty, and dividing society. This is especially unhelpful
when unanimity and collaboration are the basis to fight the outbreak, save lives and put an end to this pandemic
(Hao and Basu 2020).
Interesting to the public versus public interest

When a pandemic such as COVID-19 emerges, it is important that the authorities take necessary measures to calm
the public to avoid overwhelming responses that can create unnecessary disturbances to the situation. In such a
context, it is important to determine whether the dissemination of information is merely interesting to the public
or whether the disclosure of some information is in the public’s best interest. The distinction between these
provides guidance on how to ethically respond to information and decide when the spread of information is
necessary and ethical. It is important to ensure that the spread of information is done in an ethical and socially
responsible way as it will also help to maintain the public’s trust. This paper will now focus on the concept of
public interest to justify the act of sharing information by the public and the authorities. The concept of public
interest

Prior to embarking on discussing the problematic categories alluded to earlier, it is important to define what ‘public
interest’ means. This can be defined as the “general welfare and rights of the public that are to be recognised,
protected, and advanced” (British Medical Association 2020). A matter is of ‘public interest’ when it affects the
general public or a group within the society (Keong et al. 2016), when it raises issues of public concern, or when
there is “impact on disadvantaged or marginalised groups” (Martin 2003). Since this pandemic affects the general
public across the globe, it needs to be considered as a matter of public interest.
Disclosure of information based on the consideration of public interest during this pandemic must be weighed
against the principles that govern the basic rights of an individual such as the right to be respected for personal
autonomy, privacy and confidentiality. The benefits of disclosing the information must outweigh the harms that
may be imposed on those individuals affected with COVID-19 for the action to be justified as ethical. These
benefits should reflect an overall good to the general public to overcome this pandemic especially those aimed at
protecting the public’s safety against the disease.

Information the public considers interesting

The SARS-CoV-2 virus has the potential to infect any individual member of the community. Hence, in their effort
to understand the disease better and to avoid getting infected, the public will generally find most information,
news or stories regarding the disease interesting. Since there are still many uncertainties surrounding the risks and
nature of the disease, it is understandable that any information related to the disease would be appealing at this
stage. Journalists, bloggers or anyone with access to social media may see the pandemic as an opportunity to
obtain extra attention, increase readership rates or increase the number of their followers by publishing information
related to COVID-19. In the process of doing so, valid information may be manipulated and fabricated leading to
fake news or stories in order for it to appear more interesting to the public.
Additionally, irresponsible parties may capitalize on the public’s panic as a profiteering opportunity. Examples
of this include the marketing of fake COVID-19 home test kits and the promotion of ‘miracle cures’ which claim
to cure or prevent COVID-19 (Knight 2020). In the midst of panic, members of the public may resort to any
measures which in their opinion may protect them without verifying whether the information is accurate or
otherwise. Left unchecked, information that reaches the public can cause public uproar and may cause unnecessary
fear to the public.
Despite the previous examples, one of the main aims of disseminating information during a pandemic is to
create awareness among the public, especially regarding new discoveries and updates on COVID-19 and
emphasizing public health measures such as social distancing. Social media can be an effective platform to meet
this aim. One of the ways in identifying whether information shared is interesting to the public but not in the public
interest is when there is no beneficial impact to the public on knowing the given information.

Information considered to be of public interest

The revelation of information only becomes of ‘public interest’ when the information affects the public or is a
matter of public health policy. Such information can be seen as beneficial when knowing the information helps to
generate awareness among the public to protect themselves against the disease. It is reasonable to believe that a
common good for the public would outweigh the private interests of an individual or a few individuals. A well-
recognized shift from patient-centred duty of care to a more public-focused duties occur to ensure the safety of
the general public. This may at times necessitate utilitarian-based decisions which may not be in the best interests
of individual person (Berlinger et al. 2020). One such instance is the revealing of a COVID-19 patient’s travel
history or contact history (Department of Health 2020).
Despite the justification for the breach of confidentiality in view of public interest, there are risks attached to
this action. Social stigmatization can occur if the breach is not properly done. Information on patients can be
published widely on social media without scrutiny and may lead to the deterrence of possibly affected individuals
to come forward for investigations in fear of socially being stigmatized. As such, where a breach of patient
confidentiality is justified on the basis of public interest, the information will need to be properly examined to
ensure only accurate and necessary details are being shared to the public.

The role of a responsible public in dealing with information on COVID-19

Dealing with personal information of patients

The public may think that sharing personal information about a patient infected with COVID-19 with others on
social media is an appropriate action to show that they care about the community and to prevent further spread of
the disease. However, they may not realize that some of the consequences of this action may result in having
victimized the patient, breached the patient’s personal space on social media and the patient’s right to privacy
(United Nations 1948). In fact, members of the public should, as much as possible, refrain from sharing
information about affected patients especially when such information clearly expose personal details about them.
It is best to leave the sharing of such information in the hands of the relevant authorities.
The public should understand that there is no clear justification to the need to know in detail about a patient’s
personal information unless the information is provided directly by the authorities to the person during the contact
tracing process. Being a responsible member of the public means placing importance on respecting the privacy of
affected individuals and following the advice and directives provided by the responsible health authorities to avoid
the spread of infection.

Dealing with fake news or false information

In addition, every member of the public has the duty and responsibility to fight against fake news and inaccurate
information (Kanekar and Thombre 2019; West 2017). To win this fight, every member of the public has the
responsibility to carefully read, learn to respond and only disseminate accurate health-related information (West
2017).
On the receiving end, members of the public can protect themselves from fake news and inaccurate information
by following only verified sources and organizations with diverse standpoints and verify the validity of
information from legitimate resources. Receiving news and following updates from a small group of like-minded
opinion and belief with a limited range of resources will increase the chance for that reader to be deceived by
wrong and unvalidated information. In Malaysia, the public now has easy access in obtaining official updates from
the relevant authorities via social media platforms such as those of the Ministry of Health (MoH) Crisis
Preparedness and Response Center (CPRC) and the National Security Council Facebook pages and Telegram
channels.
In the digital world, every member of the public should have some reservations concerning the information
received from multiple sources. Digital readers need to understand that not all information published online is
factual (Wang et al. 2019). It is highly recommended that every digital consumer cultivates the skill to determine
inaccurate information to protect oneself from fake news and also from being the source of spread of the breach
of privacy of those affected. At the very least, the basic habit that all digital consumers can acquire is verifying
every received information against trusted authorities such as the National Security Council, the MoH and the
WHO. A better approach may be to acquire critical thinking skills and to enhance health and social media literacy.
This method will provide every person with the ability to critically evaluate the trustworthiness and reliability of
every health information.
In order to increase public health literacy during a pandemic, appointed public health and other responsible
authorities will need to increase their efforts in disseminating user-friendly and easy-to-understand guidelines for
targeted groups. In response to the pandemic, the Malaysian Government has shown great effort by developing
and launching the MySejahtera application to assist in managing the COVID-19 pandemic in the country by
providing basic guidelines and regular updates to the public. With the support of the government and health
authorities, responsible members of the public will have a better understanding of their significant role in helping
to enhance the country’s effort in fighting against the progressive significant social phenomenon.

The role of the authorities in responding to information on COVID-19

The sharing of personal information of patients

The principle of confidentiality is the foundation of the relationship of trust between patients and healthcare
professionals (HCPs). This relationship of trust is essential as it encourages patients to be transparent in disclosing
their medical history. However, the principle of confidentiality is not absolute. In Malaysia, the Malaysian Medical
Council (MMC) guidelines on Confidentiality (Wah et al. 2011) provide two conditions where confidentiality can
be breached without the patient’s consent. Firstly, the disclosure is permissible if it is mandated by law. For
example, in the current pandemic, the Prevention and Control of Infectious Diseases Act 1988 can be invoked
requiring HCPs to disclose personal information of patients such as their name, age, gender, ethnicity, nationality,
residential and work address to the relevant health authorities. This information enables them to perform contact
tracing and authorize an ‘enhanced movement control order’ or total lockdown in locations identified to have a
high number of confirmed cases.
Another condition where the guidelines permit disclosure without consent is when the disclosure is done for
the purpose of public interest. Since the beginning of the pandemic, the Director-General of Health has fulfilled
this role by releasing daily press statements regarding the COVID-19 status in the nation. The public is informed
daily of the number of newly confirmed cases, the number of cases being discharged, the number of cases in the
intensive care units, and the number of mortality cases. The press statement is widely reported in the media and
shared across multiple social media platforms. Additionally, the press statements would also disclose locations of
newly detected clusters and would advise members of the public who have been exposed to come forward for
testing.
The Malaysian government has been pressured at times to reveal the identity of all those infected by COVID-
19 but it has commendably never yielded to such demands (Hamid and Rahim 2020). However, even when the
patient’s personal information is anonymised, we argue that the present information sharing may have
inadvertently incited stigma against COVID-19 patients in Malaysia. In this section, we will discuss on the
strategies to overcome this.

Ending the blame in risk communication

Effective risk communication will not only alleviate anxiety and panic among the community but also educate
them to adopt necessary preventive measures. One example of an effective risk communication in Malaysia is the
daily press statement by the Director-General of Health. The consistent updates by the Director-General of Health
have allowed him to be recognized globally as a ‘top professional’ in the fight against COVID-19 (The Star 2020a).
However, the press statements on numerous occasions have arguably led to the stigma against those infected.
For example, in the case of ‘Patient 26’, a diagram that clearly linked him to 21 other patients was published on 4
March 2020 (Abdullah 2020a). The diagram implied that he was the cause for the sudden spike of COVID-19 in
Malaysia in early March. Furthermore, it was reported that he had exposed more than 200 individuals to the virus
labelling him as an ‘extraordinary spreader’ (Sukumaran 2020). This information, which was intended to warn and
educate the public, unfortunately, caused ‘Patient 26’ to be the target of criticisms by citizens all over the country.
We argue that such diagrams that link the origins of cases from one person to another are damaging even when
it is anonymised. This is evident when the never-ending harassment had necessitated the patient to publicly defend
himself (Sukumaran 2020). Similar incidents were also observed in South Korea where the public was informed
of the age, gender and movement history of each individual confirmed case via a smartphone application (Kasulis
2020). While anonymised, personal information still allowed the public to probe and discover the patients’
identities (Kim and Denyer 2020). We argue that sharing detailed information such as the diagram with the public
does not fulfil the criteria of public interest, as it would have been sufficient to inform the public of the movement
history without linking it to any patient.
Similarly, following the release of the press statement regarding the case of ‘Patient 1580’ on 5 April 2020,
unsurprisingly the public reacted negatively towards the patient. ‘Patient 1580’ was found to have infected 37
individuals, including 5 of whom had succumbed to COVID-19, as a result of her concealing her recent travel to
Italy and failing to adopt self-quarantining measures (Abdullah 2020b). In response to the disclosure, a nationwide
‘witch-hunt’ was triggered on social media after a family member of the deceased demanded that the patient
publicly apologize (Larbsib 2020). The details of ‘Patient 1580’ such as her name and pictures were later shared
on social media by individuals who had close contact with her.
It is apparent that placing the blame on anonymised patients have similar devastating effects when their
identities were later revealed. We argue that such practice by the authority may be unethical as it has the potential
to trigger needless overreactions from the public which can potentially cause the patients’ identities to be exposed.
The authorities should refrain from placing the blame on any anonymised patients as this is necessary to prevent
stigma and discrimination towards them.

Preventing discrimination against vulnerable groups

Xenophobia or prejudice against people from other countries is a common occurrence in the current pandemic. In
the beginning, Chinese nationals were discriminated all over the world (Al Jazeera 2020a) including in Malaysia.
However, this xenophobia has recently shifted to migrant workers and illegal immigrants in Malaysia. We argue
that the apparent discrimination against these groups in the country has been partly contributed by the disclosure
of the ethnicity and nationality of the newly confirmed cases to the public.
Initially, Malaysia was committed to ensuring that vulnerable groups have equal access to COVID-19 testing
and treatment. This is evident when the government announced on 30 January 2020 that all fees would be waived
for non-nationals suspected to have the virus or have close contact with confirmed cases who sought treatment in
public healthcare facilities (Ministry of Health Malaysia 2020b). However, in early May 2020, the government
announced that all migrant workers across the country must be tested, and the cost would not be borne by the
government, but rather by their employers (Anis and Bedi 2020). The announcement was a knee jerk reaction after
numerous COVID-19 clusters were discovered among migrant workers (Hassan 2020). Furthermore, reporting
the clusters as ‘security guard cluster’, ‘construction worker cluster’ or ‘foreign worker cluster’ by the mass media
is often dehumanizing (Hakim 2020; Code Blue 2020; Yusof and Landau 2020). With the growing number of
positive cases, there has been a strong pushback from the public, fearful of the virus being harboured by migrant
workers and illegal immigrants (Minter 2020).
In mid-April 2020, the Malaysian Navy turned away a boat with more than 200 Rohingya refugees on board
(Human Rights Watch 2020). Later, large scales of arrests of undocumented immigrants were made in Kuala
Lumpur on 1 May 2020, with more than 700 individuals were taken into custody (Al Jazeera 2020b). Malaysian
authorities have cited COVID-19 containment to justify both events (Ahmed 2020). The arrests have been
criticized by the United Nations in Malaysia as it may push the vulnerable groups into hiding and prevent them
from seeking treatment (New Straits Times 2020). Consequently, there have been multiple reports of migrants
who have attempted and succeeded in fleeing quarantine centres (Kaur 2020; Zolkepli and Camoens 2020).
Although the authorities had not revealed the patients’ identities, it can be argued that the sharing of their
nationalities enabled them to be stigmatized. While the collection of information such as nationality and ethnicity
may be necessary for public health interventions, the disclosure of these data to the public has no beneficial impact
to the public. Disclosing the location of new clusters without revealing the nationalities can be considered
sufficient to educate the public to adopt preventive measures.
We suggest that the information dissemination regarding the vulnerable groups should be carefully done to
prevent the public from associating them with COVID19. The mass media should avoid citing the name of the
clusters according to nationality, ethnicity, religion, or occupation to minimize the negative impact against them.

Responding to fake news or false information

Infodemic not only leads to unnecessary anxiety and panic from the public but may also breed hatred and
discrimination towards the affected communities. The Malaysian authorities have adopted two measures to contain
the spread of misinformation in the country.
Firstly, the Malaysian Communications and Multimedia Commission (MCMC), which is the regulatory body
for the communication and multimedia industry in the country, has launched a rapid response team to monitor
suspicious news or allegations made on the internet or social media regarding COVID-19 (Arumugam 2020). The
team receives and checks the facts of all suspicious social media posts, blogs or messages reported by the public.
Any social media post or article that requires clarification will be forwarded to the relevant authorities for
verification. The social media post or article in question will then be posted on the website sebenarnya.my
(translation: the truth) and labelled as fake news. As of mid-May 2020, 256 fake news have been debunked and
made public through the website.
Secondly, as of 8 May 2020, the police and the MCMC have investigated 262 individuals who were caught
disseminating fake news and false information (Arumugam 2020). Members of the public have been repeatedly
warned against disseminating fake news or false information regarding COVID-19. They have also been informed
that action against errant individuals can be initiated under Section 233(1) and 242 of the Multimedia and
Communications Act 1998, which upon conviction is liable to a fine up to RM100,000.00 or imprisonment up to
two years or both. Unfortunately, despite these warnings, fake news regarding COVID-19 remain rampant in
Malaysia, with previously debunked allegations resurfacing and being recirculated on social media. At the end of
the day, the duty falls on the members of the public to verify the information before sharing it with others.

Conclusion

Many of us are in uncharted territory and have never experienced such a pandemic during our lifetimes. These are
challenging times, and by virtue of being a part of humanity, everyone has a responsibility to work together to
overcome the challenges posed by COVID-19. In this paper, ithas been illustrated that responding in an ethical
manner when disseminating information regarding and related to COVID-19 is a positive moral duty that belongs
to everyone. For those working in the mass media, there is a need for ethical journalism; and for private individuals
who use social media, it is equally important to determine beforehand whether the dissemination of a piece of
information is interesting to the public or such disclosure of information is in the public’s interest.
The distinction of information that is disclosed in the public interest, and those that are interesting to the public,
and ethical journalism are both important because on a societal level, the public needs to remain calm and be
cooperative in efforts to prevent the spread of the disease; while on a more personal level, the sharing of personal
information can lead to stigmatization, discrimination and blame.
Press statements and news reports that assign blame on patients for ‘spreading COVID-19’ should be avoided
to prevent them from being stigmatized. In responding to the sharing of false information, the Malaysian
authorities have responded well by developing an online platform that allows the public to fact-check all
information shared across social media. Additionally, numerous criminal investigations have been initiated by the
authorities against individuals who disseminate fake news or false information. Unfortunately, the difficult part is
to ensure members of the public behave ethically. There is a strong need for the authorities to increase awareness
among the public on their ethical duty to be responsible for what they share on social media to curb infodemic and
also to prevent them from sharing unnecessary personal details of patients and affected individuals.
In responding ethically, the health and social media literacy of all citizens need to be enhanced together by
utilizing critical thinking skills to ensure that the validity of the information is checked, and the usefulness of the
information is considered before the forward or send button is clicked. In this manner, we will all be playing our
small part in this big effort to combat COVID-19, for together everybody achieves more.