COVID-19 clusters in Malaysia: characteristics, detection methods and modes of early transmission.

Objective: Effective prevention and control measures are essential to contain outbreaks of infectious diseases, such as coronavirus disease (COVID-19). Understanding the characteristics of case clusters can contribute to determining which prevention and control measures are needed. This study describes the characteristics of COVID-19 case clusters in Malaysia, the method used to detect a cluster's index case and the mode of early transmission, using the seven cluster categories applied in Malaysia. Methods: This cross-sectional study collected publicly available data on COVID-19 clusters occurring in Malaysia from 1 March 2020 to 31 May 2021. The characteristics of cases were described by category, and their associations with several outcomes were analysed. Descriptive analyses were performed to explore the method used to detect the index case and the mode of early transmission, according to cluster category. Results: A total of 2188 clusters were identified. The workplace cluster category had the largest proportion of clusters (51.5%, 1126/2188 clusters), while the custodial settings category had the largest median cluster size (178 cases per cluster) and longest median duration of cluster (51 days). The high-risk groups category had the highest mortality. There were significant differences in cluster size, duration and rate of detection across the categories. Targeted screening was most commonly used to detect index cases, especially in custodial settings, and in imported and workplace clusters. Household-social and social-workplace contacts were the most common modes of early transmission across most categories. Discussion: Targeted screening might effectively reduce the size and duration of COVID-19 clusters. Measures to prevent and control COVID-19 outbreaks should be continually adjusted based on ongoing assessments of the unique context of each cluster.

Fall determinants in hospitalised older patients: a nested case control design - incidence, extrinsic and intrinsic risk in Malaysia.

BACKGROUND: The older person is at greater risk of falls due to multiple intrinsic and extrinsic factors. This is compounded when the elderly is admitted to hospitals, as they are acutely ill and placed in an unfamiliar environment. Delirium and polypharmacy further complicate these problems. As falls reflect quality of care with potential for grave outcomes, this study aimed to identify the extent and risk of falls in public hospitals. METHODS: We conducted a nested case control study in 12 public hospitals in Malaysia. In the cohort section, we screened all inpatients 60 years of age and above daily until discharge, or the end of the study period. Daily, we identified those who fell, inclusive of near falls, in the preceding 24 h. Our enumerators interviewed patients on experience of fall, and supplemented data from the nurses and caregivers. For each case, ten controls were chosen. RESULTS: The incidence of falls/near falls was 1.0 per 1000 patient days (95% CI: 0.9, 1.1). Intrinsic risk factors found to be significant included patients who were not from a nursing home or not cared for by a domestic helper prior to admission, had prior history of indoor fall either in home or hospital, had four or more clinical diagnoses or exited from the bed on the weak side. Significant extrinsic factors were the absence of transfer bar in toilet, call bells, light switches or walking aids that were not within reach, as well as not having a walking aid. Non-sturdy chair was associated with lesser falls than when sturdy chairs with armrests were present. CONCLUSION: Querying patients for falls produced better results than incident reporting. Several intrinsic factors such as history of indoor or in-hospital fall, having four or more clinical diagnoses or exiting from weaker side and residence history may help to identify those at higher risk. Addressing significant extrinsic factors such as transfer bars and the identification of switches may help in reducing falls risk in hospitals. TRIAL REGISTRATION: This study was registered in National Medical Research Register of Malaysia ( NMRR-07-772-1044 ; date 26/05/2008) with Ethics Approval from Medical Research and Ethics Committee (MREC: MRG-07-LOI-HSR-1).

Malaysia's Health Systems Response to COVID-19.

This study aimed to highlight the COVID-19 response by the Ministry of Health (MOH) and the Government of Malaysia in order to share Malaysia's lessons and to improve future pandemic preparedness. The team conducted a rapid review using publicly available information from MOH, PubMed, and World Health Organisation (WHO) Global Research on Coronavirus Disease Database to compile Malaysia's responses during the COVID-19 pandemic. Measures taken between 31 December 2019 and 3 June 2020 were classified into domains as well as the pillars described in the WHO COVID-19 Strategic Preparedness and Response Plan (WHO SPRP). Malaysia's response incorporated all pillars in the WHO SPRP and consisted of five domains, (i) whole-of-government, (ii) cordon sanitaire/lockdown, (iii) equity of access to services and supports, (iv) quarantine and isolation systems, and (v) legislation and enforcement. Some crucial measures taken were activation of a centralised multi-ministerial coordination council where MOH acted as an advisor, with collaboration from non-government organisations and private sectors which enabled an effective targeted screening approach, provision of subsidised COVID-19 treatment and screening, isolation or quarantine of all confirmed cases, close contacts and persons under investigation, with all strategies applied irrespective of citizenship. This was provided for by way of the Prevention and Control of Infectious Diseases Act 1988. A combination of these measures enabled the nation to contain the COVID-19 outbreak by the end of June 2020.

Parenteral cytotoxic drug wastage at a tertiary hospital in Kuala Lumpur: How much and why?

PURPOSE: To identify the cost and reasons of returned parenteral chemotherapy regimens at a tertiary hospital in Kuala Lumpur, Malaysia. METHODS: Data were retrospectively extracted from all the Chemotherapy Return Forms in 2016, which is a compulsory documentation accompanying each return of parenteral chemotherapy regimen. The following data were extracted: patient's diagnosis, gender, location of treatment (i.e. ward/daycare clinic), start date of chemotherapy regimen, type of cytotoxic drug returned, dose of cytotoxic drug returned, number of cytotoxic drug preparations returned and reason for return as well as whether the returned cytotoxic drug preparations could be re-dispensed. The cost of wastage was calculated based on the cost per mg (or per unit) of the particular returned cytotoxic drug. RESULTS: One hundred and fifty-nine cases of returned chemotherapy regimen comprising of 231 parenteral cytotoxic drug preparations were analysed. The total cost of returned chemotherapy regimen for 2016 was €3632, with €756 (20.8%) worth of chemotherapy regimens returned due to preventable reasons and €2876 (79.2%) worth of chemotherapy regimens returned due to non-preventable reasons. Approximately 50% of cases returned chemotherapy regimen were due to deterioration of patient's clinical condition and another 24.5% of cases of returned chemotherapy regimen were attributed to adverse drug reactions. CONCLUSION: Wastage associated to non-preventable reasons such as adverse drug reactions and preventable causes like refusal of patients can be further reduced by using newer healthcare innovations and establishment of written institutional protocols or standard operating procedures as references for in-charge healthcare personnel when cytotoxic drug-related issues occur. Adoption of cost-saving strategies that have been proven by studies could further improve current cost containment strategies.

Stability of apomorphine in solutions containing selected antioxidant agents.

Apomorphine in solution undergoes rapid autoxidation, producing greenish colored solutions, making it difficult to formulate as a stable pharmaceutical solution. To identify the optimum antioxidant agent/combination for apomorphine solution, a high performance liquid chromatography assay was used to study the stability of 50 µg/mL apomorphine HCI in 0.1% L-ascorbic acid (AA), 0.1% sodium metabisulfite (SMB), 0.1% EDTA, and in selected combinations at 25°C, 32°C, and 37°C over a period of 14 days. The stability of apomorphine HCl (10 mg/mL) in 0.1% AA solution and in 0.1% EDTA solution at 25°C and 37°C was also evaluated. Apomorphine HCI solution (50 µg/mL) in 0.1% AA plus 0.1% SMB solution retained 99.7% (at 25°C) and 95.9% (at 37°C) of the initial concentration, as 0.1% AA plus SMB solution minimized the reactive oxygen content in solution which, in turn, reduced the oxidation rate of apomorphine HCl, and there was no green coloration perceptible. Conversely, apomorphine HCl solution (50 µg/mL) in 0.1% SMB solution was unstable as only 0.53% (at 25°C) and 0.06% (at 37°C) of the initial concentration was retained after 14 days. All 10 mg/mL apomorphine HCl samples were stable in both studies. The initial concentration of apomorphine HCl solution markedly affected its rate of oxidation and discoloration. The addition of 0.1% AA to a current formulation of apomorphine HCl injection (Apomine®), which contains SMB as an antioxidant, was recommended as providing the most stable solution.