PEJABAT TIMBALAN KETUA PENGARAH KESIHATAN (KESIHATAN AWAM) KEMENTERIAN KESIHATAN MALAYSIA (OFFICE OF THE DEPUTY DIRECTOR-GENERAL OF HEALTH (PUBLIC HEALTH) DEPARTMENT OF PUBLIC HEALTH (QUAY OF HEALTH MALAYSIA) /ARAS 8, BLOK E 10, KOMPLEKS No, Tel.: 03-8883 4016 PUSAT PENTADBIRAN KERAJAAN PERSEKUTUAN, No. Faks 03-8883 4030 162590 PUTRAJAYA, MALAYSIA, Ruj. Tuan « ‘Ruj. Karni :KKM,600-29/4/146 JLD 6 ( 6) Tarikh = Ss Oktober 2020 SENARAI EDARAN YBhg. Datuk / Dato’ Indera / Dato’ / Datin / Tuan / Puan, SURAT EDARAN BERKAITAN KEMASKINI KES DEFINISI! DAN GARIS PANDUAN PENGURUSAN KES COVID-19 DI MALAYSIA Dengan segala hormatnya perkara di atas adalah dirujuk. 2. Untuk makiuman YBhg. Datuk / Dato’ Indera / Dato’ / Datin / Tuan / Puan, berdasarkan dapatan saintifik berkaitan gejala yang dialami oleh pesakit COVID-19 sepanjang tempoh pandemik ini, Pertubuhan Kesihatan Antarabangsa (WHO) telah mengemaskini kes definisi bagi pengesanan kes COVID-19. Terdahulu, kes definisi yang dikeluarkan oleh WHO adalah lebih menjurus kepada gejala salur pernafasan akut (Acute Respiratory Infection (ARI)). Walau bagaimanapun, setelah pelbagai dapatan saintifik diperolehi, gejala yang dialami oleh kes COVID-19 tidak hanya terangkum bagi gejala ARI sahaja. Oleh yang demikian, pihak WHO telah mengemaskini garis panduan kes definisi COVID-19 pada laman sesawang WHO pada bulan Ogos 2020 yang lalu. 3. Justeru, KKM juga telah meneliti beberapa garis panduan berkaitan antaranya garis panduan daripada; WHO, Centre for Disease Control (CDC) Amerika Syarikat, kes definisi beberapa negara lain dan juga dapatan kajian epidemiologi terkini berkaitan gejala jangkitan COVID-19. Susulan itu, KKM telah mengemaskini kes definisi COVID-19 di Malaysia (Annex 1, Guidelines COVID-19 Management in Malaysia No. 05/2020). Kes definisi yang telah dikemaskini ini meliputi kes definisi bagi “suspected case” dan “probable case” manakala kes definisi bagi “confirmed case” dan juga “Person Under Surveillance” masih dikekalkan seperti sediaada.4. Dengan adanya pertambahan kes definisi “suspected case” ini, penggunaan kes definisi bagi “Patient Under Investigation (PUI)” tidak akan digunapakai lagi, dan kategori ini telah ditukar kepada “Suspected Case”. Bersama ini juga disertakan senarai annex yang telah dikemaskini bersama dengan kes definisi yang baharu (Lampiran 1). 5. Sehubungan itu, adalah dipohon kerjasama YBhg. Datuk / Dato’ Indera / Dato’ / Datin / Tuan / Puan untuk memaklumkan kepada semua fasiliti kesihatan di bawah tanggungjawab masing-masing tentang perkara yang dinyatakan di atas. Dokumen ini juga boleh diperolehi dari laman sesawang rasmi COVID-19 KKM melalui pautan: http://covid-19.moh.gov.my/garis-panduan/garis-pai in-kkm 6. Untuk makluman, penggunaan kes definisi ini berkuatkuasa serta merta dengan tarikh surat ini dikeluarkan. Sebarang pertanyaan lanjut mengenainya boleh dikemukakan kepada pegawai-pegawai berikut: Nama Pegawai_ : Dr. Wan Noraini Wan Mohamed Noor No. Telefon 103 - 8884 4119 E-mel : drwnoraini@moh.gov.my Nama Pegawai_ : Dr. Siti Aisah Mokhtar No. Telefon 103 - 8884 2115 E-mel : aisahmokhtar@moh.gov.my 7. Perhatian dan kerjasama YBhg. Datuk / Dato’ Indera / Dato’ / Datin / Tuan / Puan berhubung perkara ini adalah dihargai dan didahului dengan ucapan terima kasih. Sekian. " BERKHIDMAT UNTUK NEGARA " Saya yang menjalankan amanah, (DATO’ DR. IG CHEE KHEONG) Timbalan fa Pengarah Kesihatan (Kesihatan Awam) Kementeri&n Kesihatan Malaysiask. Ketua Pengarah Kesihatan Malaysia Timbalan Ketua Pengarah Kesihatan (Perubatan) Kementerian Kesihatan Malaysia Timbalan Ketua Pengarah Kesihatan (Penyelidikan & Sokongan Teknikal) Kementerian Kesihatan Malaysia Pengarah Bahagian Kawalan Penyakit, KKM Pengarah Bahagian Perkembangan Perubatan, KKM Pengarah Bahagian Pembangunan Kesihatan Keluarga, KKM Pengarah Bahagian Perkembangan Kesihatan Awam Pengarah Bahagian Pendidikan Kesihatan Pengarah Program Perkhidmatan FarmasiSENARAI EDARAN Pengarah Makmal Kesihatan Awam Kebangsaan (MKAK) Sg. Buloh, Selangor Pengarah Institut Penyelidikan Perubatan (IMR) Pengarah Kesihatan Negeri Jabatan Kesihatan Negeri Perlis Pengarah Kesihatan Negeri Jabatan Kesihatan Negeri Kedah Pengarah Kesihatan Negeri Jabatan Kesihatan Negeri Pulau Pinang Pengarah Kesihatan Negeri Jabatan Kesihatan Negeri Perak Pengarah Kesihatan Negeri Jabatan Kesihatan Negeri Selangor Pengarah Kesihatan Negeri Jabatan Kesihatan WP Kuala Lumpur & Putrajaya Pengarah Kesihatan Negeri Jabatan Kesihatan Negeri N. Sembilan Pengarah Kesihatan Negeri Jabatan Kesihatan Negeri Melaka Pengarah Kesihatan Negeri Jabatan Kesihatan Negeri Johor Pengarah Kesihatan Negeri Jabatan Kesihatan Negeri Pahang Pengarah Kesihatan Negeri Jabatan Kesihatan Negeri Terengganu Pengarah Kesihatan Negeri Jabatan Kesihatan Negeri KelantanPengarah Kesihatan Negeri Jabatan Kesihatan Negeri Sarawak Pengarah Kesihatan Negeri Jabatan Kesihatan Negeri Sabah Pengarah Kesihatan Negeri Jabatan Kesihatan WP Labuan Pengarah Hospital Kuala Lumpur Pengarah Institut Kanser Negara Pengarah Pusat Darah Negara Ketua Pengarah Perkhidmatan Kesihatan Markas Angkatan Tentera Malaysia Bahagian Perkhidmatan Kesihatan Kementerian Pertahanan Malaysia Chief Executive Officer (CEO) Institut Jantung Negara Pengarah Pusat Perubatan Universiti Malaya Lembah Pantai, Kuala Lumpur Pengarah Hospital Universiti Sains Malaysia Kubang Kerian, Kelantan Pengarah Hospital Canselor Tuanku Muhriz UKM Cheras, Selangor Pengarah Hospital Universiti Putra Malaysia Serdang, SelangorKetua Pengarah Klinikal Hospital Universiti Teknologi MARA. Sungai Buloh, Selangor President Malaysian Medical Association (MMA) Tingkat 4, Bangunan MMA 124, Jalan Pahang 53000 Kuala Lumpur President Academy of Family Physicians of Malaysia Suite 4-3, Tingkat 4, Bangunan MMA 124, Jalan Pahang 53000 Kuala Lumpur Master Academy of Medicine of Malaysia G-1 Bangunan Akademi Perubatan 210, Jalan Tun Razak 50400 Kuala Lumpur President Association of Private Hospitals of Malaysia A-17-01, Menara UOA Bangsar No. 5, Jalan Bangsar Utama 1 59000 Kuala Lumpur President Primary Care Doctor’s Organisation Malaysia (PCDOM) 2, Jalan SS3/31, University Garden, 47300, Petaling Jaya, Selangor President Medical Practitioners Coalition Association of Malaysia (MPCAM) No. 17-2, Jalan PJS 8/12, Dataran Mentari (Sunway) 46150 Petaling Jaya SelangorChief Executive Officer (CEO) Malaysia Healthcare Travel Council (MHTC) Level 28, Lot 28-01, Tower 2, Menara Kembar Bank Rakyat Jalan Travers 50470 Kuala LumpurLAMPIRAN 1 SENARAI ANNEX YANG TELAH DIPINDA PADA 5 OKTOBER 2020 (4.7 Annex 1 [Case Definition of COVID-19 2. | Annex 2 |Management of Suspected, Probable and Confirmed COVID-19 3._| Annex 2a_| Management of Suspected Case As Outpatients 4. | Annex 2b | Management of Suspected Case Required Admitted To Ward | 5. | Annex 2c | Screening and Triaging 6. | Annex 2d | Work Process of Pre Hospital Care And Emergency And Trauma Department 7. | Annex 2f | Flow Chart For Sampling COVID-19 By Private Health facilities 8. | Annex 2h | Management of Probable COVID-19 Case 9. | Annex 2i | Field Investigation Form COVID-19 10. | Annex 9 | Guidelines For Entry Point Screening Of Travellers During Recovery Movement Control Order (RMCO)- Screening for COVID-19 11. | Annex 10a_| Home Assessment tool (Bahasa Melayu) 12. | Annex 10b | Home Assessment tool (Bahasa Inggeris) 13. | Annex 12_| Management of Close Contact of Confirmed Case 14. | Annex 13_| Field Response Activity 15. | Annex 24 | SOP For Performing Radiological Procedure For Suspected and Confirmed COVID-10 Patient 16. | Annex 42 | MySejahteraAnnex 1 Annex 1: Case Definition of COVID-19 1. Suspected Case of COVID-19 A person who meets the clinical AND epidemiological criteria: a. Clinical criteria In the absence of a more likely diagnosis: oR At least two of the following symptoms: * Fever Chills Rigors Myalgia Headache Sore Throat Nausea or Vomiting Diarrhea Fatigue Acute onset Nasal congestion or running nose ii. Any one of the following symptoms: oR * Cough * Shortness of Breath © Difficulty in Breathing Sudden new onset of anosmia (loss of smell) Sudden new onset of ageusia (loss of taste) ili, Severe respiratory illness with at least one of the following: © Clinical evidence of pneumonia * Acute respiratory distress syndrome (ARDS) b. Epidemiological criteria Attended an event OR areas associated with known COVID-19 cluster OR red zones"; OR Travelled to / resided in a foreign country within 14 days before the onset of illness; OR Close contact? to a confirmed case of COVID-19, within 14 days before onset of illness.2. Probable Case of COVID-19 A person with RTK Ag positive awaiting for RT-PCR confirmation OR A suspect case with chest imaging showing findings suggestive of COVID-19 disease (refer Annex 24). Note : Radiological imaging procedure Is not indicated in all suspected COVID-19 unless there is clinical suspicion of pneumonia. 3. Confirmed Case of COVID-19: A person with laboratory confirmation of infection with the COVID-19, lmrespective of clinical signs or symptoms. 4. Person Under Surveillance (PUS) for COVID-19 Asymptomatic individual subjected to Home Surveillance Order (HSO) ' The list of red zone areas is based on the 14 days moving data by mukim/zon/presint updated dally in the CPRC telegram : https://t.me/eprokkm ?Close contact defined as: * Health care associated exposure without appropriate PPE (including providing direct care for COVID-19 patients, working with health care workers infected with COVID-19, visiting patients or staying in the same close environment of a COVID-19 patient). * Working together in close proximity or sharing the same classroom environment with a with COVID-19 patient * Traveling together with COVID-19 patient in any kind of conveyance © Living in the same household as a COVID-19 patientAnnex 2 ‘Annex 2: MANAGEMENT OF SUSPECTED, PROBABLE AND CONFIRMED COVID-19 CASE 4. OVERALL MANAGEMENT OF COVID-19 IN MALAYSIA. easconTECnON macucH mummesouncts sot sm OUD: et A/a reason COME 6 scraning for rahi eas “interes ath Rages fos Pa FP) ee ee + emer rw Cn for Sanne COMO by Pte Sptaes Pena fortes COMO Desh anaaatanT over Maneperent Seach nd ine yt ore Yemen Ton ie Marga eee DST | J = tt F>7 Rae > Aa ania en co Toner 38 COW pie owas tm oi + om ren ue nestnin enact tba on 88 5, Ain Giese exten ys mo 82D) 1 Aten eoungsones Supe cov + Andis osm of 1 Aimer 2: sof Premine toolapa! Poeste for Supe Canna COMD-9 Pate Mart neath - Aes 38: eral ath and prsac uppert awouescnplng — Laeeo sm omerer Figure 1 : Overall management and response of COVID-19 cases in Malaysia.2. CRITERIA FOR HOSPITAL ADMISSION FOR SUSPECTED, PROBABLE AND CONFIRMED CASE . All COVID-19 cases confirmed (Laboratory confirmed case)! . All Probable COVID-19 cases Suspected COVID-19 who is clinically il Suspected case with uncontrolled medical conditions, immunocompromised Status, pregnant women, extremes of age (< 2 years or > 60 years old) . Suspected case who does not fulfil the above criteria but are not suitable for home surveillance, to consider admission in quarantine station (Annex 32) a, b. c. d. » COVID-19 positive from low risk group who are asymptomatic or mildly symptomatic can be admitted directly to low risk COVID-19 quarantine and treatment centres after discussion with relevant physician, * The clinical condition of the patient is based on clinical judgement of the clinician in-charge 3. CHECKLIST FOR SUITABILITY OF SUSPECTED CASE TO UNDERGO HOME SURVEILLANCE: (The checklist is provided as a guide, hence the assessment of patient suitability for home surveillance is tailored from one patient to another). a. Has a separate bedroom with en-suite bathroom (preferable); if not, common bathroom with frequent disinfection b. Has access to food and other necessities c. Has access to face mask, glove and disinfectant at home d. Able to seek medical care if necessary and retum with own private transport €. Able to adhere to instruction to follow home surveillance order f, Able to stay away (at least 2 meter apart) from the high-risk household members (e.g, individual > 60 years old, young children <2 years, pregnant women, people who are immunocompromised or who have chronic lung, kidney, heart disease) 4, CONFIRMED CASE OF COVID-19 All confirmed case need to b * Admitted to Admitting Hospital (as mentioned in section 2) * Notified and registered as COVID-19 case to PKD as soon as possible. * Transported to Admitting Hospital by designated transport arranged by PKD * Managed clinically as per recommendation in Annex 2e * Field Investigation by PKD as per Annex 135. CRITERIA FOR TRANSFER TO A STEP-DOWN FACILITY 2 Confirmed case of COVID-19 who fulfilled the following criteria a. At least seven days have passed since symptoms first appeared AND b. At least three days (72 hours) have passed since recovery of symptoms (defined as resolution of fever without antipyretics and improvement in respiratory symptoms [e.g., cough, shortness of breath]) AND stable co- morbids Patient can be transferred to identified Step Down Centers until discharge. Step Down Center can be from an Identified ward in district hospital or an area which is suitable within the acute hospital. The coordination and management of these centers is under the responsibility of the hospital. Daily monitoring by medical personnel must be done in this center. . CRITERIA FOR DISCHARGE FROM INFECTIOUS DISEASE WARD FOR CONFIRMED COVID-19 CASE 6.1.Patients with laboratory-confirmed COVID-19 can be discharged from infectious disease ward or released from COVID-19 Care Pathway when fulfil the following criteria: a. Person with COVID-19 who have symptoms: At least 10 days have passed since symptom onset And At least 24 hours have passed since resolution of fever without the use of fever-reducing medications And Other symptoms such as dyspnoea, cough have improved b. Person infected with SARS-CoV-2 who never develop COVID-19 symptoms: Maybe discharged 10 days after the date of their first positive RT-PCR test for SARS-CoV-2 Note: No COVID-19 test is required before patient Is discharged from the ward. For immunocompromised hosts such as those on chemotherapy, bone marrow or organ transplantation, HIV with low CD4 cell count and prolonged use of corticosteroids or other immunosuppressive, releasing from COVID- 19 care pathway has to be taken on a case to case basis.6.2. Confirmed covid-19 case requiring prolonged in-patient care @. COVID-19 cases fuffiling the discharge criteria above but still requiring Ongoing inpatient care such as stroke rehabilitation can be discharged from COVID care and transferred to the appropriate ward, b. Category 5 patients in ICU, who still require ICU care beyond 28 days of illness, can also be discharged from COVID care. This is based on recent data that infectious viruses have not been isolated beyond day 20 of illness even in those critically ill. 6.3, Examples of Scenarios for the Discharged of COVID-19 Case a, Scenario 1: Severe Illness ¢. Discharged from ICU at day 12 of illness on nasal prong Oxygen d. Off oxygen at day 14 of illness @. Recovered with minimal cough and no exertional dyspnoea on walking to toilet, diabetes and hypertension well controlled at day 18 of illness f. Conclusion: Fit for discharge at day 18 of illness b. Scenario 2: Mild lliness * Mildly symptomatic on admission with no pneumonia (Day 5 of illness). * Asymptomatic after day 3 of admission (Day 8 of illness) * Conclusion: Fit for discharge at day 10 of illness (Day 5 of admission) ©. Scenario 3: Admission during pre-symptomatic period * On admission patient is asymptomatic, however develops symptoms on day 2 of admission. Symptoms subside after 5 days. * Conclusion: His onset of illness starts from day 2 of admission. Fit for discharge at day 10 of illness (Day 12 of admission) G. Scenario 4: Residual disease * Admitted for CVA and found to be positive COVID-19 * Pneumonia but does not require oxygen * Conclusion: Discharged from COVID-19 ward and can be transferred to stroke ward at day 10 since the date of COVID-19 diagnostic test Positive. 7. POST DISCHARGE PLAN FOR CONFIRMED COVID-19 CASE a. For patients with co-morbidities, to arrange appointment for the follow-up at the nearest health facilities and to ensure adequate supply of medications until the next appointment. Brief summary should be prepared upon discharge. b. Upon discharge, all patients should be provided with the hospital's contact number and health education pamphlet (Guideline for COVID-19 PatientDischarged from Hospital) as in Appendix 1. 8. 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Soy OF Yoduway werep yes YrAel neve SuejnIog ziefoB —ueyeBuaw —epue eXUBITNES “somes puey, Laue? reduojou 2 nee 4e uep unges ueyeundbvou ous unaired 2 duet weduee ueboer ne = e “oven words woidu!s 1848164 see, seo p wl ep J ik huey Buedoy rexewoUl Uerelesig eons Se es ust uss is @ ies 2 ee rap mous eum yey desey tsowie uenBdueg [eIS08 ueyelelued UeyRyeI |__‘anwenuseowmem _eweavmmomoney amin |ANNEX 2a Annex 2a : Management Of Suspected Case As Outpatients 1. Patients who come to any health facilities should be screened for suspected COVID-19 at triage. a. Refer Annex 1 for case definition b. A special area should be set up for COVID-19, to which he / she can come directly to be assessed. It is also recommended that the dedicated team be assigned where possible. (Refer to the flowchart below) 2.IF PATIENT MEETS THE CRITERIA OF SUSPECTED COVID-19 CASE: Consult Physician-on-call / Physician in-charge of screening centre for decision on whether: * The definition of suspected case is fulfilled and further review of patients at screening centre is needed * The definition of suspected case is fulfilled and admission to admitting hospital is required (Annex 2) Suspected case has been ruled out 3. For suspected case who do not require admission, the case shall be referred to the nearest screening hospital / centre using either: © own transport OR designated ambulance from MECC 4. For suspected case who requires admission, the case shall be transferred to admitting hospital using designated ambulance as above. 5, Management of suspected case at screening hospital / centre a. Suspected case from General Practioner clinic / private hospital shall be reassessed by screening hospital / centre on the need for admission b. Screening hospital / centre to inform the admitting hospital if admission is needed c. Suspected case shall be sent to the admitting hospital using designated ambulance. d, Those suspected case who do not fulfill admission criteria will be assessed for suitability of home surveillance (refer checklist in Annex 2)e. If home surveillance is deemed suitable (refer the following flow chart) © Sample shall be taken at ‘screening hospital / centre © They shall be sent home and put under Home Surveillance Order for 14 days (Annex 15a) © Samples of suspected case should be sent to identified Hospital Laboratory (Annex 4a) ‘© Explain to patient regarding home surveillance, COVID-19 infection and tisk of transmission to family and community o Provide Home Assessment Tool (Annex 10a or 10b) © Notify suspected case of COVID-19 to PKD. f. If home surveillance is deemed unsuitable, to consider admitting patient to a quarantine station (Annex 32) All patients fulfilling suspected case of COVID-19 criteria require notification to the nearest PKD using notification form as soon as possible (Annex 7). INFECTION PREVENTION AND CONTROL (IPC) - refer to Annex 8 1, All health care workers involved in managing the suspected case shall adhere to the Infection prevention and Control Guideline at all time. 2. Personal Protective Equipment (PPE) shall be used per recommendation in the Infection Prevention and Control Guideline in Annex 8Flow Chart of Management of Suspected Case Not Admitted ‘Aperson tuffil criteria for Suspected Case (refer Annex 1) ] Ful Criteria for Admission (Annex 2) ‘Screening centre CY ir + Take 1* sample and sent to designated lab (Annex 4a) + Explain regarding COVID-19 infection and risk of transmission to family Reterfor admission in and community + Ask patient to download and registered into MySejahtera app ~ Annex 42 dota Poste | + Give patient Home Assessment Tool (Annex 10) together hand-cut? (annex2>) pamphlet about COVID-19 infection ‘Notify suspected case to PKD and il patient information into eCOVID Pejabat Kesihatan Daorah (PKD) “Assisted by UKA Hospital where available Visit case at home Serve Home Survellance Order + Conduct 14 days survelance (le. from the date of last exposure to case Using Annox 15) + Refercase back to screening hospital if case has worsening of symptoms + Update information at e-COVID | reyneam gress new sympa developed L Continue home survellance to complete l¥symptom progress /new symptom developed - Discharge home survellance at Day ] 14 + Setve release order (annex 17ANNEX 2b Annex 2b : Flow Chart of Management of Suspected Case Admitted to Ward Apeton ul ctr for Suapected Cee (rte Anext) | [erwin | ~ Preparedto transport janie ADMITTING HOSPITAL (Annex 3) ~ Contact infestous Disease Specialist n-charge/ Physician On al at ‘amiting Hospital, + Nfy PRO ~ PAD fo coordinate abulance ranspertto Aditing Hospital (reer Amex " ~ PD fo send the patient to ADMITTING HOSPITAL (Annex 3) for ‘dmiselon = Notify suspected ease to PKD an fl patent information into &-COMID No Rewew in Emergency Deparment (roterannex 24) He Sent ‘Treat symplomatealy, Annex 2e(Cinical Menegement ‘of Contimed Case) = Repeat samp as insisted + Conthue Viard Management unt ft lscharge cemtra (Annex 2) NEGATIVE PosmivE Repeat sample str 48-72 ours Tolnically Full discharge ingestes extra (Annex 2) Conte Wars Management Discharges, + Ascpaient to downland td egistered ino Seite app ‘+ Tointorm PKD once paint ciacharge + Toupdateaceace autzome in &COVIO }+ Toinform PkD once patent discharge trom ward + PKDto serve home suvelance orcerto complete 14 ‘ys (to continue managemant as Arnex 20) + Ask patent to downioad and registered ino MyStiehtra sppAnnex 2c ANNEX 2c : SCREENING AND TRIAGING 4. PRIVATE FACILITIES Private Clinic + Provide good visual signages in all relevant languages requesting patients to declare symptoms, travel or contact with a confirmed case + Through verbal and visual cues, identify those with respiratory symptoms and offer masks and hand sanitizer Rapidly assess verbally if the patient has epidemiological criteria that might qualify him/her as a suspected case. (refer to Annex 1) If uncertain, discuss with medical / Infectious disease specialist at nearest screening hospital + If suspected case identified: - place patient in a pre-designated waiting area’ - Take patients identifiers (name, IC/passport, telephone number, address) for notification to PKD (and arranging transport if necessary) - Inform with Physician-on-call / Physician in-charge of screening centre - Patient may use his/her own transport to nearest screening hospital (public transport not allowed) - If patient does not have private transportation, contact PKD for transport arrangement. + After patient leaves — disinfect waiting area 'Pre-designated area = more than 1m away from other patients and staff ~ minimal surrounding items to minimize items requiring disinfecting Private Hospi * Provide good visual signages in all relevant languages requesting patients to declare symptoms, travel or contact with a confirmed case * Through verbal and visual cues, identify those with respiratory symptoms and offer masks and hand sanitizer * Clinically assess the severity and whether the patient qualifies as a suspected case (in isolation room using appropriate PPE). * If uncertain, discuss with medical / Infectious disease specialist at nearest screening/admitting hospital * If severe cases (hypoxic or presence of exertional dyspnea) - Contact admitting medical / ID specialist at admitting Hospital to arrange for admission.- If case accepted, to contact PKD to arrange transportation. If mild case (asymptomatic or mildly symptomatic): - Take patients identifiers (name, IC/passport, telephone number, address) for notification to PKD (and arranging transport if necessary) = Inform with Physician-on-call / Physician in-charge of screening centre - Patient may use his/her own transport to nearest screening hospital (public transport not allowed) - If patient does not have private transportation, contact PKD for transport arrangement. After patient leaves — disinfect isolation room If the patient does not fulfill suspected case criteria, but clinical suspicion remains, take samples and send to designated private laboratories (Annex 4a) 2. GOVERMENT FACILITIES Patients who come to the respective health facilities should be screened for suspected COVID-19 at triage. A special area should be set up for suspected case of COVID-19, to which he / she can come directly and to be assessed there. The suspected case should be managed by a dedicated team where possible. WHEN SHOULD YOU SUSPECT COVID-197 COVID-19 is to be suspected when a patient presents to Triage Counter with the following: Attended an event or areas associated with known COVID-19 cluster or red zones oR Travelled to / resided in foreign country within 14 days before the onset of illness OR Close contact’ in 14 days before illness onset with a confirmed case of COVID- 190R Should a patient fulfill the description, to institute infection prevention and control measures as the following: - Place patients at least 1 meter away from other patients or health care workers. Clinics and Emergency Departments are to prepare an isolation area / room for patients. - Ensure strict hand hygiene for all clinic staffs and suspected patient. - Provide surgical mask to patients if not contraindicated. - Personal protective equipment as per recommendation should be worn at all times.- After the encounter, ensure proper disposal of all PPE that have been used ~ Decontamination of the isolation area and equipments used should be done. A group of suspected case who come to any healthcare facilities in a specific vehicle (e.9. bus, van) should be contained in that vehicle until being evaluated by a dedicated team to minimize exposure to healthcare workers and other patients. NoTr |tis not always possible to identify patients with COVID-19 early because some have mild or nonspecific symptoms. For this reason, it is important that health care workers apply standard precautions and wear surgical mask consistently with all patients — regardless of their diagnosis in all work practices all the time. 10ANNEX 2d GUIDELINES ON THE MANAGEMENT OF SUSPECTED AND CONFIRMED COVID- 19 PATIENTS IN THE EMERGENCY MEDICINE AND TRAUMA SERVICES Introduction This guideline is produced based on the current available data and resources in the management of suspected COVID-19 patients. The primary objective of this guideline is to facilitate the health care workers (HCW) in the Emergency and Trauma Department (ETD), in carrying out the management of suspected COVID-19 patients, hence, optimizing the screening, detection, isolation and institution of therapeutic intervention. Early risk detection is paramount in ensuring effective prevention and control of the disease. Additionally, it also: 4) Serves to protect the HCW from being exposed to COVID-19. 2) Advocates the separation of walk-in patients with respiratory symptoms and without respiratory symptoms as early as primary triage contact. This will minimize the risk of disease transmission to the HCW and other patients in keeping with the WHO guidelines in IPC for infectious diseases. 3) Address the functions of Prehospital Care and Ambulance Services (PHCAS) in various aspects of COVID-19 operations. General guidelines 1) All Emergency and Trauma Departments (ETD) should be prepared to receive the following case scenarios (Figure 1): a) Walk-in or referred patients should be screened for suspected cases of COVID- 19 (Figure 2). b) Walk in patients with RTK antigen results or probable cases of COVID -19. c) Patients being referred for hospital admission. This will only apply if the ETD is part of the hospital regarded as Admitting Hospital based on MOH Guidelines (Annex 3). 2) All ETDs should use their internal pathway to isolate or screen walk-in patients from the triage to ensure appropriate infection prevention and control 3) The PHCAS should be prepared in providing the following functions a) Screening for COVID-19 risk factors for all emergency calls received requesting ambulance response either through MERS999 or direct lines. b) Provision of Emergency Ambulance Service for medical assessment, intervention, and transportation for probable, suspected or confirmed COVID-19. ©) Provision of Interfacility Transport service for patient transfer between health facilities, screening centres, admitting hospitals and quarantine stations. d) Provision of specialised transport services for critically ill patients or those classified as Highly Infectious Disease (HID) patients.ANNEX 2d ©) Supporting various agencies to mitigate the hazards posed by infectious disease in the aspects of provision of technical medical advice and response. EMERGENCY AND TRAUMA DEPARTMENT Leh Referred Patents Walain Patients p= | Rofer to Figure 2: For Admission For Screening Management 1 worktow for patient suspected for (Govid-19 in ETO ni using ens pathway for Covi-10 ‘admission at Adiiting Hospital Institute resuscitation and treatment Designates ‘Admiting Hosptal for Covie-192 Refer ID Physician in ‘Aiming Hosptal J Communicate with EP ‘Admiting Hosptat J Prepare team for transfer ‘Transfer acmiting hospital, Figure 1: General workflow for probable, suspected or confirmed COVID-19 patients in ETD admission at Admiting HospitalANNEX 2d Figure 2: General method of COVID-19 screening for non-referral walk-in patients in ETD PHCAS Emergency Call Screening for COVID-19 Risk Factors (Figure 3) 1) All calls requesting for ambulance service either through 999 or facility direct lines shall be screened for COVID-19 risk factors. 2) Screening uses a combination between geographical location of the incident and patients’ own tisk factors. 3) Once risk factor has been identified, the following must be performed: a) Responding team is advised on Personal Protective Equipment use - Protect the Team. b) Alert the responding team to the transport destination for the patient - Screening Centre, Admitting Hospital or Designated Hospital. ¢) Maintain communications with the responding team on the clinical status of the patient. 4) MECC will direct the transport of patients to the right facility based on clinical acuity and MOH guidelines. 5) MECC will alert and coordinate with the receiving facility on reception of the patient to the right area or ward.ANNEX 2d ] T tonsa ® seognons cre ance Renee) ] fees” ‘weiss ent ce “ening ty set Figure 3: Management of 999 Calls by MECC during Infectious Disease Outbreak or Pandemic PHCAS: Inter-facility Transfer Coordination for Suspected or Confirmed Infectious Patients (Figure 4). 1) This protocol is only activated once referral communication between Referring Facility and 'D Physician of Admitting Hospital has been performed and the patient transfer is accepted. 2) This requires coordination between the MECC, Referring Facility ambulance team and Admitting Hospital Bed Management Unit (BMU) or ward. Objective of the communication is to minimize time waiting in the ambulance for the preparation process in the Receiving Facility. 3) Basic information needed for MECC to perform this task are: a) Name and contact number of doctors from referring facility. ) Patient demographic details (name, age, gender, IC) ©) Patient clinical condition - critical care, highly infectious or stable for admission. d) Name of person and contact number of Receiving Facility Admission Unit 4) Clinical condition of the patient will determine the ambulance and team appropriate to. provide care for the transfer.5) 6) 2) 8) 9) ANNEX 2d Communication with the referring facility doctor will assist in determining use of the right ambulance for the transfer. MECC will coordinate ambulance assistance for the Referring Facility that has no in-house ambulance service. Communication with the Admitting Hospital BMU or ward will determine the schedule of transfer. Any prolonged waiting time should be escalated to the Emergency Physician. The Emergency Physician would balance the needs of patient, transport, and preparedness of the ward. Once logistics of team, vehicle and time has been established then the transport is initiated. Communication and coordination are terminated once a patient has been confirmed to arrive safely in the designated Receiving Facility.ANNEX 2d Treial conction Ragas ‘Specials Tangpor Team or Retieval? ‘dict eer to 10 Physiean Seememiatewm socom | anna eas ence ‘earspon srangements cated forthe tepate. ‘Communicate with Admiting Host ‘BMU er ward on preparedness fo recede patent Lo oO Inte Transter Process wth ‘Transpo Team | — | Montor raster unt ones aval ‘patent to Admiing Pospia aie i om { earmurieaton process win eter Fzlyt eeordnateretioval of {fel paver. ‘Scheduling of time fr anspor ie based on preparedness ot ‘ating Heap Ware ‘raster tine hathas prolonged; wating time (nore tn 90 i anes) in prima eter tacy Sroud ave a mechan fo Update pater canaton. Te ‘egures ierventon fan Emagen Physician fo batance Ie needs of patent anspor ana preparedness of host Infectious Disease Pat nts, Figure 4: Coordination of Inter-facility Transfer of Suspected or ConfirmedANNEX 2d Preparation of an Ambulance for Transport of Suspected or Confirmed Infectious Disease Patient. 4) Finding the Right Ambulance for the Transport. a) Ambulance should have separated the driver and patient compartment area b) Air flow in the ambulance should be separated between driver and patient ‘compartment area. ©) Air flow in the patient compartment should be from paramedic seat to rear end (stretcher loading area). 4) Patient compartment ventilation should be facilitated by the Heating Ventilation Air Conditioning (HVAC) with air exhaust system. e) Air flow in the ambulance compartment during movement or static should be maintained at more than 6 air exchange per hour 2) Preparing the Ambulance for Transport a) All unnecessary equipment for the care of transported patients should be removed or stored into a bag that can be secured and cleaned after response. b) Equipment that is anticipated to be used for the care of patients should be packaged into grouping such as Airway, Ventilation and Circulation. This will reduce difficulty in decontamination of exposed equipment. ¢) Stress should always be on terminal cleansing of the ambulance rather than encapsulation of ambulance fittings. Doffing of encapsulation carries the same risk as doffing of PPE. 4) Always have a spillage kit available in the ambulance. 3) How many patients should be transported in an ambulance? a) Itis advisable to only transfer one patient per ambulance. The space constraint and ventilation in an ambulance makes it a risk for cross infectivity between patients if more than one is present. b) Transport of more than one patient in the ambulance can be considered in a special population or situation, Medical Direction from an Emergency Physician is required for this purpose to safeguard safety of patients and staff in the ambulance. ) Whenever there are more than 3 patients to be transferred in a single response; then the use of alternative transport than an ambulance should be considered such as vans or coasters or bus or even trucks. 4) Terminal Cleaning and decontamination of ambulance or patient transport vehicles. a) Staff performing the cleansing process must adhere to PPE recommendation by IPC. Team, The PPE should be similar to that wom by staff performing terminal cleansing in hospital faci b) There are several methods of terminal cleaning of vehicles or ambulance: i) Clean and wipe using the recommended solution.ANNEX 2d ii) Vapour distribution method using manufacturer or IPC recommended solution and device, ill) Ultraviolet Germicidal irrac ion. ©) Ifa solution is used then it must adhere to recommendation by the IPC Team. However, care must be used to get a solution that is least corrosive to the materials and upholstery in the ambulance. 4) Prior to beginning the terminal cleaning process, look around the ambulance patient compartment and identify any gross contamination such as blood, vomitus or any other bodily flu. @) Gross contamination must be cleansed first, before proceeding with terminal cleaning. 5) Cleaning and disinfection of medical equipment. 1) Reusable medical equipment must be cleansed based on manufacturer or IPC recommendation. ») Monitor cables must be wiped using IPC recommended disinfectant wipes after use for every patient. 6) Personal Protection Equipment for Personnel Involved in Transport of Suspected or Confirmed Infectious Disease Patient. a) The type of PPE used in an ambulance is determined by the acuity and infectivity of a patient, b) Ambulance is an enclosed environment with limited ability for distancing. Thus, use of PPE should be emphasized at all times especially when transporting a patient without the use of a Patient Transport Isolation System, TARGET ACTIVITY ‘TYPE OF PPE PERSONNEL Driver ‘Involved in driving the patient | » Surgical mask with suspected, probable or * Isolation Gown (fluid- confirmed COVID-19 BUT NO repellent long-sleeved direct contact with the patient. gown) OR long-sleeved © Also involved in loading and Plastic apron unloading of patients * Gloves ‘+ Always maintain at foot end of | » Eye Protection (face stretcher shield/goggles * Windows should be kept open throughout the drive (about 3cm only) *_Use HVAC with fresh air intake Healthcare | © Transporting suspected, © N95 mask worker probable or confirmed COVID- | © Isolation Gown (fluid- (Hew) 19 patient to the referral health repellent long-sleeved care facility gown) * Gloves * Eye Protection (face shield/goggles) * Head coverANNEX 2d 7) The seating arrangement in an ambulance is a dynamic process based on acuity, infectivity and seats available in the ambulance. Paramedic Patient Condition Type of Intervention Seating A © Normal patient with low monitoring None requirement © intubated patient with patient transport Airway isolation system B © Critically il patient Circulation! Medication c ‘* Normal patient with low monitoring None requirement ‘* Can also be used to sit second patient of same risk 8) Patient preparation prior to boarding of the ambulance: a) Patients that can tolerate use of face masks should be provided with a face mask. b) Nasal prong oxygen can be used inside a face mask. ¢) Rebreathable oxygen masks can be used inside a face mask. Caution when using face mask over a non-rebreathable oxygen mask d) Awake patients should be asked to sanitize their hands prior to boarding into an ambulance.ANNEX 2d €) Patients can be seated at the side chair or propped up into seating position on the stretcher. f) Use of safety belts must be ensured, 9) Patients with high oxygen requirements should be informed to an Emergency Physician. h) Directive on need to intubate the patient with ‘subsequent retrieval must be considered to prevent performing aerosol generating procedures during transfer. 9) Special Considerations on Transport of Highly Infectious Disease Patients (HIDP). a) Patient Transport Isolation System (PTIS) are available to be used in transporting HIDP. b) The use of PTIS require a specialised team that are: i) Care and use of the system. li) Adaptation of medical procedures with the system. ¢) Each type of PTIS has its advantages and limitation on: i) Vehicle space requirements for its use, ji) Clinical acuity of patients suitable for its use. Some PTIS require patients to lie supine only. iii) Environment suitable for the PTIS operations,ANNEX 2d Management of patient referred for screening in ETD 1) The Primary Team Physician (ID Physician, Physician or Paediatrician) is responsible to inform the dedicated Screening Hospitals ETD (based on the MOH list of screening hospitals) on the patient's arrival. 2) The ETDs will screen the patient using the method similar for walk-in patient, which includes the assessment of patient's stability. The expected outcomes are: a) Patient fulfils suspect or probable case criteria and requires hospital admission b) Patient fulfils suspect case criteria but does not require hospital admission; patient will be discharged under home surveillance (Annex 2a). c) Patient fulfils suspect case criteria but does not require hospital admission however unsuitable for home surveillance. Patient should be considered to be admitted in quarantine station. d) Patient who does NOT fulfil suspect or probable case criteria but fulfils criteria for surveillance swab will be managed according to SARI or relevant guideline. e) Patient who does NOT fulfil suspect or probable case criteria, or criteria for surveillance swab will be treated accordingly. 3) Patients who are admitted to the hospital will follow the existing hospital's admission process for COVID-19 patients (Annex 2b). 4) Patients who are being transferred to another facility for admission will be transported based on the current local protocol agreement for interfacility transfer. Communication between the referring and the referred Emergency Physicians (EP) should occur prior to transport. Management of patient referred for admission 1) The Primary Team Physician is responsible to inform the Admitting Hospital ETD on the patient's arrival, his/ her clinical status and also the designated ward. 2) Patients who are admitted to the hospital will follow the existing hospital's admission process for COVID-19 patients (Annex 2b).ANNEX 2d Specific guidelines for HCW in the ETD 1) Patient with respiratory symptoms/ acute respiratory infection (ARI) must be reminded to wear surgical mask (if tolerable). If not tolerable, patient should be advised to cover the nose and mouth during coughing or sneezing with tissue or flexed elbow. 2) HCW are advocated to wear appropriate PPE based on the treatment zones and type of procedures. 3) HCW attending ARI patient should wear appropriate PPE as per guidelines. a) Surgical mask b) Long sleeved plastic apron ©) Gloves 4) Eye protection (face shield/goggles) 4) HCW performing aerosol generated procedures (AGP) in ARI area such as intubation, nebulization, high flow mask more than GL/min, open suction, oropharyngeal or nasopharyngeal swab and etc should wear appropriate PPE as per guidelines. a) N95 mask b) Isolation gown (fluid-repelient long-sleeved gown) ©) Long sleeved plastic apron d) Gloves e) Eye protection (face shield/goggles) f) Head cover 9) Boot cover/shoe cover (ONLY when anticipate spillage and vomiting) 5) Patient without respiratory symptoms/ non acute respiratory infection (non-ARI) can stil be infected with COVID-19 particularly in the presence of epidemiology link. They can present with non-respiratory symptoms such as fever, lethargy and rarely diarrhoea, a) It is pertinent for HCW to identify and manage them in a designated area with appropriate PPE (e.g. isolation room, decontamination room). b) If patient fulfils suspect or probable criteria, COVID-19 test should therefore be Performed. This is to ensure effective infection prevention and control. 6) Administration of oxygen driven nebulization is not recommended for asthmatic and COPD patients with mild to moderate exacerbation. Utilization of MDI via spacer is advocated instead to prevent the HCW from AGP exposure. 7) Provision of nebulized bronchodilators is only reserved for patients with severe exacerbation.ANNEX 2d 8) For management of SARI patients, please refer to Ministry of Health Guidelines on Infection Control and Clinical Management of Severe Acute Respiratory Infections/ Pneumonia TRO COVID-19.ANNEX 2f FLOW CHART FOR SAMPLING OF COVID-19 BY PRIVATE HEALTH FACILITIES N.B: This flow chart should be used together with Annex - Screening and Triaging, Guidelines on COVID-19 Management in Malaysia Client request for COVID-19 test (RT-PCR) I Preparation: Nasopharyngeal AND Oropharyngeal sampling set and VTM_| ‘Triple packaging set for transportation of samples Biohazard waste bin & bag, PPE (e.g: Shoe cover, double gloves, head cover, isolation gown, apron, face shield/ google, NOS mask) Laboratory form 6. Disinfectants ™ -— ‘Take samples and do triple packaging v Collection of samples by the private laboratory v Private laboratory conduct test ‘and key in ALL samples taken into SIMKA To advise cent to practise: = Wash hands frequently + Practice Respiratory Hygiene + Social distancing |—_ If develop symptoms to seek medical care early RESULT NEGATIVE RESULT POSITIVE Send result to Doctor to Doctor to notify provide health PKD & refer advice to client client (CRC- Criss Preparedness & Response centre | KN: fbatan Keslhatan Negeri PKD-Pejabat Keinatan Daerah 1D Infectious Diease CRITERIA FOR SAMPLING ~ Asymptomatic = Not Suspected Case (refer ANNEX 1) = No history of contact with confirmed case of COVID-19 = Team should consist of THREE trained healthcare workers ~ All team members should wear appropriate PPE and carry their identification tags Private doctor: | 1. To advise clent to wear Face mask 2. To notty respective PKD ‘immediately either through phone all fax or email (Annex 7) 2. To contact PKD for transport arrangement immediately (PKD to refer to Annex 11) 3, To contact I physician ofthat ‘admitting hospital to inform about the case (refer Annex).Probable Case of COVID-19 (refer to Annex 1) + leolate th patent +, Aiways maintain IPC whe wating to transport the patient to Admiting Hospital + Toot BKD immeditaly and fil up the elieaon for Kein resut info SIMKA PD to coordinate ambulance transport to Admiting Hospital (refer Annex 14) PKD to send he patient to ADMITTING HOSPITAL (Annex 3) for admission RTK-Ag positive, send buffer solution for RT-PCR topether withthe potent te the Admitting Hospital (refer Annex 4c) “tte paint edited toa hosp! with PCR facies, the confematory test could be cone as @ flowchart n Annex fein the respective hasta ‘Pleaso onsure who waiting forthe result, th c200 wil be sooted and IPC ‘measures should be maintanod (All probable case should be managed as Confirmed COVIO-19 case unt {aboratory-contirmed result available) Annex 2h Annex 2h : Flowchart for Management of Probable Case of COVID-19 exo Noto register yet untl conte laboratory postive + PKD to nite ald investigation, case Investigaon & dented contact) whe waiting forte isoratery confmaton + To followup wih the hospital on the status of ‘he patent ‘Admit te pate * Isolate the patent whe wating forthe confirmatory resut + Take a fesh sample for RT-PCR and refer Annex 4e + The cinical Management same ae Annex 2 “reat accordingly * Upon discharge iform PKC for update + Por dlecharge * To counsel patent regarding the final laboratory ting Treat accordingly Ginical Management of Confimed COVID-19 Case (Annex 26) + To update PKD the laboratory result PKO to register as confirmed COVID-19 case and keyin Information into e-COVID PKD to continue pubic heath intervention (refer Annex 13) “ H prebable ease is an indivigual with RTK-Ag positive, walting for RT-PCRAnnex 2i Annex 2i : INVESTIGATION FORM COVID-19 DISTRICT HEALTH OFFICE: a) DEMOGRAPHIC Name 5 _IC/passport No. (If Malaysian travellers, please _obtain both IC and passport No.) Date of birth Age Gender | Nationality : Country Origin Contact no. : Current Address in Malaysia (home/accomodation) Occupation & Address of workplace b) EPIDEMIOLOGICAL LINK i, History travelling to affected country : YES / NO {IFYES, please complete the box below) a. | Affected country travelled to b. | Date departure from affected country c._| Date of entry to Malaysia : Point of entry to Malaysia e. | Mode of transport into : Malaysia f. | Flight no, & seat no /vehicleno | : (kindly please provide details of ALL flight / mode of transportation used)g. | Any transit Yes / NO h. | Places & date of transit 2 2) 3) i. | Address in affected country |__| (home/accomodation in affected country) ii. History of exposure to confirmed/probable COVID-19 case : YES / NO Date of last exposure iil, History coming back from red zone / ar eas : YES/NO Red Zone Area Visited Date coming back from red zone area iv | History visited other healthcare faci ies before diagnosis. : YES/ NO Name of healthcare facilities Date of visiting 1 ‘Any other identified epidemiological risk : ¢) COVID-19 STATUS Date of diagnosis E Date of notification Date of investigation Date of admis Admitting Hospitald) SIGN & SYMPTOM. Signs and symptoms Date of onset |. At least TWO of this following Fever chill Rigors Myalgia Headache Sore Throat Nausea / Vomiting Diarrhea Fatigue Acute onset Nasal Congestion or running nose li, Any ONE of the following Cough Shortness of Breath Difficulty in Breathing Sudden new onset of anosmia (loss of smell) |__Sudden new onset of ageusia (loss of taste)) MOVEMENT HISTORY (please include movement history outside Malaysia if the case was a traveler coming back from overseas) Day Date Details of Daily activities Contact (Place went) {name & phone) 14 days before onset 13 days before onset 12 days before onset 11 days before onset 10 days before onset 9 days before onset 8 days before onset 7 days before onset 6 days before onset 5 days before onset 4 days before onset 3 days before onset 2 days before onset 1 days before onset onset 1 day after onset 2 days after onset 3 days after onset 4 days after onset 5 days after onsetf) UST OF CLOSE CONTACTS (please also include close contact identified from other countries for the case coming back from overseas for IHR notification) Name ‘Age | Gender Relationship | Date of last with contact | contact | Contact No. 8) NAME OF HEALTHCARE WORKERS INVOLVE IN MANAGING THE CASE (DR./SN/PPP/PPKP/DRIVER/OTHERS) Name Name of Facility | Position h) LABORATORY INVESTIGATION [Date of first sample taken Type of test conducted (rt-PCR/RTK-Ag) | Date of sample sent to laboratory Name of laboratory Date received result Result (positive/negative) | if positive please write CT-value Contact Tracing i) CONTROL AND PREVENTION DONE BY DISTRICT HEALTH OFFICE Activities Date Notes Active Case Detection Health Education Home surveillance Disinfe OthersCOMMENT BY DISTRICT EPIDEMIOLOGIST Name: Designation: Date & Time: COMMENT BY STATE EPIDEMIOLOGIST Name: Designation: Date & Time:ANNEX 9 GUIDELINES FOR ENTRY POINT SCREENING OF TRAVELLERS DURING RECOVERY MOVEMENT CONTROL ORDER (RMCO) (SCREENING FOR COVID-19) A. ADVICE TO TRAVELLERS BEFORE DEPARTURE (refer Guidelines Entry and Quarantine Process Person Under Surveillance (PUS) arriving from abroad by NADMA Malaysia) 1. Sign a Letter of Undertaking and Indemnity (LoU). All individuals traveling to Malaysia must download and complete the LoU via the following link (i) Ministry of Foreign Affairs Malaysia: www.kin.gov.my (ii) National Disaster. + Management Agency (NADMA): www.nadma.gov.my (iil) Immigration Department of Malaysia: www.imi.gov.my (iv) Ministry of Health Malaysia: www.moh.gov.my (v) Ministry of Transport Malaysia: www.mot.gov.my (vi) Ministry of Tourism, Arts and Culture Malaysia: www.motac.cov.my Obtain a Letter of Approval (Entry Permit) from an accredited Malaysian Mission 3, Present the Letter of Approval from the Malaysian Mission to Airlines, Other Public Transport Companies, and the Immigration Department of Malaysia 4. All are required to install, activate, and register the MySejahtera application (https:/mysejahtera.malaysia.gov.my/). The mobile application can be downloaded at Apple Appstore, google play store, and Huawei App gallery. Essential information such as travel information (date and time, flight information, a port of embarkation) as well as health declaration needs to be registered in the MySejahtera application at least one (1) day from date of departure. p a B. ONBOARD SCREENING OF AIRCRAFT TRAVELLERS AND CABIN CREWS FROM AFFECTED COUNTRIES (AS PER THE WHO WEBSITE) FOR SUSPECTED CORONAVIRUS DISEASE 2019 (COVID-19) 4, Measures On Board Flight (for All Flights from Affected Countries) 4.1 Announcements The flight pilot of the aircraft shall make in-flight announcements. These announcements shall be made during the flight and just before landing. ii, These announcements shalll include the following messages: a. During flights The need for cabin crew to announce the requirement of travellers with symptoms to identify themselves to the airline crew, for example, ‘Any traveller with symptoms of COVID-19 infection such as fever, cough, sore throat and breathlessness to identify themselves to the crew’.ANNEX 9 b. Upon Landing * Advised travellers to install and register the MySejahtera Application and fill up the Health Declaration Form (HDF) (Appendix 1- new) in the application. * Inform travellers that they need to undergo a thermal scanning upon arrival. 1.3. Visual Assessment Crew members must be vigilant on travellers who have symptoms (fever, cough, sore throat, and breathlessness) that did not identify themselves. 1.4, Management of travellers with symptoms of COVID-19 by airlines crew i. The aircraft pilot needs to inform the authorities of the destination airport regarding travellers with COVID-19 Infection symptoms as soon as possible. ii, The symptomatic traveller is given protective masks (three-ply mask) and shifts them to an empty area of the aircraft if possible. If not, vacate two rows in front and two rows at the back of the traveller with symptoms, iii, Identify a separate toilet for suspected travellers only. iv. The crew must wear a protective mask and disposable gloves. The crew should wear a face shield (advisable). v. The pilot/crew of the aircraft is to identify the close contacts of the suspected travellers. vi. The close contacts of the suspected traveller are: * Any person sitting within 2 metres (4 rows in front, side and behind) of the suspected case ‘* Any travel companions or person providing care who has close contact with a suspected case * crew managing the case on-board * anyone having contact with respiratory secretions of the infected traveller, The pilot and co-pilot of the aircraft are sitting in a cockpit are less risk of contact with the infected traveller and not considered as close contact. vi, If a crew is a suspected case of COVID-19, travellers served by him/her are categorized as close contact and manage accordingly. viii. Close contacts should provide their contact number and address to the health authorities, ix. The crew has to fill up the Traveller Locator Form for suspected cases (Appendix 2). x. Write all measures taken on-board and record it in the Report of Measures Taken Onboard Form (Appendix 3). xi. Submit both Appendix 2 and Appendix 3 to health officials upon arriving.1.5 ANNEX 9 Management of travellers with symptoms of COVID-19 by the health authority i. Public Health Team (medical doctor, Nurse/Medical Assistant, and Assistant Environmental Health Officer) are station at the arrival gates. ii, The team will go on-board to announce the health inspection procedure. The team must also request for the traveller locator form (Appendix 2), report of measures taken on-board (Appendix 3), and a general declaration of health and flight manifest. iii, The airline crew informs the health team on symptomatic travellers. The symptomatic travellers will be tagging with red tags, The travellers identified are to be given appropriate protective masks (3-ply) and are to be shifted to the rear of the aircraft if possible. Else, vacate two rows in front and two rows at the back of the symptomatic traveller. iv. All travellers except those suspected COVID-19 infections will be allowed to disembark the aircraft to proceed to COVID-19 symptoms screening. v. Symptomatic travellers will be interviewed and examined. If fit the criteria of the suspected case of COVID-19: a. Refer the case to the hospital for further management and COVID- 19 test. b. Notify to health authorities in those areas in which the contacts reside (DHO and State CPRC). vi, The health authority must inform the airline management regarding the Suspected or positive COVID-19 case and direct them to disinfect the affected airlines. vii. Any positive COVID-19 case on board, the health authority (respective DHO) need to; ‘* Initiate contact tracing for *close contact of positive cases (traveller and crew). * Take the COVID-19 test, issue HSO, and home quarantine for 14 days for all close contact of positive case (traveller and crew). * DHO needs to work with the KLIA health office to issue HSO and take the COVID-19 test among the affected airline crew. *refer 1.4.vi for the definition of close contact.