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Abstract The currentEbolaoutbreak,which is thefirst to affectWestAfrican countries,hasbeendeclared to have met the conditions for a Public Health Emergency of International Concern(PHEIC)bytheWorldHealthOrganization(WHO).Thus,theMinistryofHealth(MOH)ofMalaysiahastakenstepstostrengthenandenhancedthefivecorecomponentsofpreparednessandresponsetomitigatetheoutbreak.TheNationalCrisisPreparednessandResponseCentre(CPRC)commands,controlsandcoordinatesthepreparednessandresponseplansfordisasters,outbreaks,crisesandemergencies(DOCE)relatedtohealthinacentralisedway.ThroughstandardisedcasedefinitionandmandatorynotificationofEbolabypublic andprivatepractitioners, surveillanceofEbola ismadepossible.GovernmenthospitalsandlaboratorieshavebeenidentifiedtomanageanddiagnoseEbolavirusinfections,andmedicalstaffmembershavebeentrainedtohandleanEbolaoutbreak,with emphasis on strict infection prevention and control practices. Monitoring of the points ofentryandtravellersandstudentsvisitingorcomingfromWestAfricancountriesismadepossiblebyinteragencycollaborations.Toalleviatethepublic’sanxiety,effectiveriskcommunicationsarebeing delivered through various channels.With experience in past outbreak control, theMOH’spreparednessandresponseplansareinplacetoabateanEbolaoutbreak.

Keywords: Ebola, Ministry of Health Malaysia, preparedness, response, outbreak

Introduction

Ebolavirusdisease(EVD)isasevereillnesscaused by infection with a virus of the familyFiloviridae, genus Ebolavirus. There are fiveidentifiedsubspeciesofEbolavirus,ofwhichfourcause disease in humans. These subspecies aretheEbolavirus(Zaire ebolavirus;EBOV),Sudanvirus(Sudan ebolavirus;SUDV),TaïForestvirus

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Responding to the Potential of Ebola Virus Disease (EVD) Importation into Malaysia

Wan Noraini Wan MohaMed noor1, Sukhvinder Singh Sandhu1, Husna Maizura ahMad Mahir1, Devan Kurup1, Norhayati ruSli1, Zainah Saat2, Chee Kheong Chong3, Lokman Hakim SulaiMan4, Noor Hisham abdullah5

1 Surveillance Section, Disease Control Division, Level 6, Block E10, Complex E, Ministry of Health Malaysia, Federal Government Administrative Centre, 62590 Putrajaya, Malaysia

2 Surveillance Section, Disease Control Division, Level 6, Block E10, Complex E Ministry of Health Malaysia, Federal Government Administrative Centre, 62590 Putrajaya Malaysia

3 Office of the Director of Disease Control Division, Level 3, Block E10, Complex E Ministry of Health Malaysia, Federal Government Administrative Centre, 62590 Putrajaya, Malaysia

4 Office of the Deputy Director General of Health (Public Health), Ministry of Health Malaysia, Federal Government Administrative Centre, 62590 Putrajaya, Malaysia

5 Office of the Director General of Health Malaysia, Ministry of Health Malaysia, Federal Government Administrative Centre, 62590 Putrajaya, Malaysia

Submitted: 25Oct2014Accepted:27Oct2014

(Taï Forest ebolavirus; TAFV) and Bundibugyovirus (Bundibugyo ebolavirus; BDBV). TheReston virus (Reston ebolavirus; RESTV) hascauseddiseaseinnon-humanprimates,butnotinhumans(1).EVDisassociatedwithacasefatalityrate of up to 90%. Recently, the term “Ebolavirusdisease”hasbeguntobeused(ratherthantheearlier termof “Ebolahaemorrhagic fever”),considering that haemorrhage is not observed

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inallpatients intheoutbreakoccurringinWestAfrica (2). To date, the 2014 Ebola outbreak isthe longest, largest andmost widespread Ebolaoutbreak in history and the first inWest Africa(3).ThisoutbreakstartedinGuineainDecember2013butwasonlyreportedtotheWorldHealthOrganization (WHO) in March 2014 and laterspread toLiberia, SierraLeone andNigeria (4).On 8 August 2014, theWHO declared that theconditions for a Public Health Emergency ofInternationalConcern(PHEIC)hadbeenmetbytheEVDoutbreakinWestAfrica(5).

Preparedness and Response

Five core components of preparedness andresponsewereidentifiedbytheMinistryofHealth(MOH)inrespondingtothepossibilityofanEVDoutbreakinMalaysia,asfollows:

a) Command;b) Surveillanceandriskassessment;c) Medicalandlaboratoryresponse;d) Publichealthinterventions;e) Communication

These core components were strengthenedto ensure an effective, appropriate and timelyresponse, thus fulfilling the preparednessrequirement.

Command The National Crisis Preparedness andResponse Centre (CPRC), which is the nationalcommand centre for infectious diseasesurveillance under the MOH, was establishedunder the 9th Malaysia Plan (2006-2010) forthe management of health-related crises anddisasters(6).ThesolepurposeoftheCPRCistobeacentralnervepointforthecommand,controlandcoordinationofthemanagementofdisasters,outbreaks,crisesandemergencies(DOCE)atthenationallevel(Table1).TheCPRCvigorouslyandcontinuously monitors the development of theEVDsituationinternationallyandlocally,withco-operation and collaboration with the respectiveagencies.Inlinewithprovidingthelatestupdateson the development of the Ebola outbreak, theCPRC channels the information to the relevantlocalstakeholdersforappropriateaction.

Surveillance and risk assessment Ebola is listed as one of the mandatorynotifiable diseases in Malaysia under the

PreventionandControlofInfectiousDiseaseAct1988(Act342)(7).Itisalsooneofninenotifiablediseases that need to be reported within 24hours by telephone, in addition to submissionoftheprescribedform.Withthis legalprovisionin place, both public and private practitionersare required to promptly report EVD cases thathave been detected. Commonly, notificationof infectious diseases by medical practitionerswho treat or become aware of the existence ofan infectious disease casewithin their premisesis made to the nearest District Health Office,where the information will be entered into anonlinesystemknownas ‘eNotifikasi’.TheonlinesystemisaccessibletotherespectiveStateHealthDepartment and the Disease Control Division,MOH.InviewofthetimelyresponserequiredforEVD management, an administrative directivehasrecentlybeenissuedtosimultaneouslyinvolvethethreeparties in thenotificationprocess(i.e.,thenearestDistrictHealthOffice, therespectiveState Health Department and the DiseaseControlDivision,MOH,via theCPRC).Todate,the MOH has received several notifications ofsuspectedEVD cases, better known as a personunder investigation for EVD (PUI-EVD), butnone was confirmed to be positive. To ensuresmooth surveillance for EVD, a standardisedcasedefinitionisbeingused(Table2),whichwasadoptedbasedonthecasedefinitionproposedbythe Centers for Disease Control and Prevention(CDC),Atlanta,USA(8). A risk assessment of the potential of EVDimportation into Malaysia was conducted inresponse to the outbreak (the methodology forthis assessment was adopted from the WHOmanual)(9).Basedonthisassessment,theoveralllevelofriskwasestimatedtobelow,particularlyif returning travellers and health care providersareproperlyinformedandareawareoftherisk.Information related to the EVD outbreak inWestAfricahasbeendisseminatedtoMalaysiantravellerssinceApril2014withtheassistanceoftheMinistryofForeignAffairs.Internally,withintheMOH,thisinformationhasbeencirculatedtothe health care community nationwide throughtheStateHealthDepartmentsatthesametime.

Medical and laboratory response Thesafetyofhealthcarepersonnelisoftheutmost importance where Ebola is concerned.Therefore, these personnel are continuouslyremindedabout the importanceof adherence tostrict infection prevention and control practicesto avoidunintentional spreadofEbola infectionwithin health care settings. The availability of

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appropriatepersonalprotectiveequipment(PPE)is taken into account to facilitate the successof such practices. To ensure safe patient triagethroughoutthehealthcaresystem,21governmenthospitalswereidentifiedforimmediatereferralofeachPUI-EVDnationwide.OncetheindividualisconfirmedtobepositiveforEVDinfection,he/shewillbeimmediatelytransferredtooneofthethreedesignated hospitals for further management.These hospitals are Sungai Buloh Hospital,Selangor (for managing confirmed cases within

PeninsularMalaysia);QueenElizabethHospital,Kota Kinabalu (for managing confirmed casesfromSabahandtheFederalTerritoryofLabuan);andGeneralHospital of Sarawak (formanagingconfirmed cases within Sarawak). Nevertheless,health care personnel are reminded aboutprompt notification of each PUI-EVD throughthe established channel, which is critical for atimely response by those undertaking the fieldinvestigation. The Institute for Medical Research (IMR),

Table1:TheNationalCrisisPreparednessandResponseCentre(CPRC),MinistryofHealth(MOH)Malaysia

Establishment● TheNationalCPRChasbeenestablishedunder the9thMalaysiaPlan(2005–2010)aspartof

thestrategiestoeffectivelymanagedisasters,outbreaks,crisesandemergencies(DOCE)relatedtohealth

● WasofficiatedbythethenMinisterofHealth,Dato’Dr.ChuaSoiLekon7May2007Functions● General:

Theprimaryresponsibilityistoactasacommandcentreforcoordinationofallpublichealthactivitiesrelatedtocrisispreparedness,responseandrecoveryphasesinmanagingDOCE

● Specific:- StrengtheningthelevelofMOHpreparedness- Establishment of strategies to address public health issues and recovery in the event ofrespondingtodisasters

- Coordinateallhealth-relatedactivitiestoensureeffectiveandimmediateresponse- Reducemorbidity andmortality before, during and after the event through the adoption ofmulti-sectoralapproach

- Enhancing collaboration and coordination: international organizations, non-governmentalorganizations(NGOs),privatesectorincludingpharmaceuticalcompaniesandlaboratories

Table2:InterimCaseDefinitionforEbolaVirusDisease(EVD)PersonunderinvestigationforEVD(PUI-EVD):● Apersonwhohasbothconsistentsymptomsandriskfactorsasfollows:

Clinicalcriteriawhichincludesfeverofgreaterthan38.6degreesCelsiusandadditionalsymptomssuch as severe headache, muscle pain, vomiting, diarrhea, abdominal pain, or unexplainedhemorrhage;and

● Epidemiologicriskfactorswithinthepast21daysbeforetheonsetofsymptoms,suchascontactwithbloodorotherbodyfluidsorhumanremainsofapatientknowntohaveorsuspectedtohaveEVD;residenceinortraveltoanareawhereEVDtransmissionisactive*;ordirecthandlingofbats,rodentsorprimatesfromdisease-endemicareas

Probablecase:● APUIwhoisacontactofanEVDcase,regardlessofthelevelofhis/herexposureConfirmedcase:● AcasewithlaboratoryconfirmeddiagnosticevidenceofEbolavirusinfection*OutbreakaffectedcountriesincludeGuinea,SierraLeoneandLiberia(asof20October2014)

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which is a biosafety level (BSL) 3 laboratory, isinchargeofconductingthe laboratorydiagnosisofEVDbyviralgenomedetectionusingreal-timereverse transcription polymerase chain reaction(rRT-PCR). In preparation for a possible surge,withtheavailabilityofappropriateinfrastructure,staff members from the National Public HealthLaboratory (NPHL) Sungai Buloh were trainedin themanagementofsamples fromaPUI-EVDand in laboratory testing for diagnosis of EVD.Later, in view of the logistic constraints facedby the health care facilities of East Malaysia,the ability to perform laboratory diagnosis ofEVDwas further extended to the PublicHealthLaboratory Kota Kinabalu, Sabah. In addition,aspartofpreparednessindealingwithanEbolaoutbreakinMalaysia,theIMRorganisedtraininginBSL3practicesamongnineBSL2laboratories,comprisingMOHlaboratoriesandonelaboratoryfrom the armed forces. This training was forroutinelaboratorytests. AguidelineonEVDmanagementinMalaysiawas circulated nationwide in September 2014.The guideline covers various pertinent issues,as were mentioned earlier, including forensicmanagement of EVD cases andmanagement ofclinicalwaste,linens,theenvironment,andotheraspects with regards to EVD cases. A briefingsession involving the key players was organisedtoensurethataclearunderstandingwasgatheredfrom the circulated guideline. Furthermore,simulation exercises focusing on preparednessand response activities forEVDwere conductedat various levels of the MOH of Malaysia. Inaddition,theMOHofMalaysiaparticipatedinanEVD simulation exercise that was organised bytheRegionalOfficefortheWesternPacificoftheWHOinearlyOctober2014.

Public health interventions InthecontextofpublichealthinterventionsregardingapotentialEVDoutbreakinMalaysia,priority is given to rapid deployment of theidentified Rapid Response Team (RRT) andRapid Assessment Team (RAT) for executionof the field investigation activities. Theseactivities include contact tracing and referral ofsymptomaticcontacts to thedesignatedhospitalusing dedicated medical transportation. Theseteamsareconstantlyremindedoftheimportanceof practising optimal infection prevention andcontrolmeasuresatalltime. Malaysia is a popular destination forforeign students and tourists from the affectedcountries. Therefore, strengthening of publichealth interventions is warranted to prevent

the potential occurrence of EVD infection inMalaysia.Therequiredmechanismisinplacetofurtherenhancetheinteragencycollaborationstocurbsuchanundesirableoutcome. Through collaboration with the Ministryof Education, close monitoring of the healthstatus of students arriving from the affectedcountries has been made possible. In addition,the MOH is working closely with partners atMalaysia’s international points of entry (e.g.,the Immigration Department of Malaysia andthe airport/seaport/causeway authorities) toidentifytravellerscomingfromaffectedcountrieswho show signs of illness. Such travellers willbe referred to the Health Quarantine Centreor to health care personnel stationed at thosepremises for further management. BecauseGuinea, Liberia, Nigeria and Sierra Leone arelistedasseveralofthecountriesatriskofyellowfevertransmission,travellerscomingfromthosecountriesaresubjectedtoyellowfeverscreeningat the international points of entry. With theongoing EVD outbreak, the existing screeningwas further enhanced. Currently, there are nodirectflightscomingfromtheaffectedcountriestoMalaysia.Nevertheless,HealthAlertCardsforEVD are distributed to incoming travellers andto the crewmembers of airlines from the EVD-affectedcountriesarrivinginMalaysiaviavariousconnectingflights. With the assistance of Ministry of ForeignAffairs, a travel advisory has been issued toMalaysians, recommending avoidance of non-essential travel to the affected countries. Thehealth status of Malaysian nationals stationedin the affected countries is monitored throughfeedback gathered from both the Ministry ofForeign Affairs and the Ministry of Defence.Concurrently,thepotentialtransmissionofEbolavirus through the importationof liveanimalsoranimalproducts isbeingcloselymonitoredwithassistance from the Department of VeterinaryServices and the Department of Wildlife andNational Parks (PERHILITAN), which areconducting a study acquiring local serologicalevidence of Ebola involving local wildlife, andespeciallyfruitbats.

Communication Effective risk communication is paramountin alleviating the anxiety of the general public.Hence, the MOH is constantly engaging thepublic and concerned parties by utilising all oftheavailablechannelsofcommunication.Regularupdates are disseminated to the public throughpressstatementsissuedbytheMinisterofHealth

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or the Director General of Health, forums ortalkshowsbroadcastedontelevision,theofficialMOH website and the MOH and its NationalCPRC Facebook pages. The public is beingmade aware of common signs and symptomsofEVD, preventive steps to be taken if they wereto travel to the affected countries and what towatchforuponreturninghomefromtheaffectedcountries. Through thesemeasures,we are ableto communicateandeducate thegeneralpublic,thusmaintainingtheirawarenessofandalertnesstowardsEVD.

Conclusion

National preparedness in responding topotential EVD importation into Malaysia isvitaltomitigatethenegativeimpactnotonlyonhealth but also on economic and social aspects.Strengthening of our national preparednessand response capacities should be built uponthe foundation laid for pandemic influenzapreparednessand the important lessons learnedfrom responses to various outbreaks occurringlocally, such as Nipah virus encephalitis in1998-1999, severe acute respiratory syndrome(SARS)in2002-2003andtheinfluenzaA(H1N1)pandemic in2009.Valuableexperiencehasalsobeen gained from dual incidents in 2014: thedetectionofourfirstlaboratory-confirmedcaseofavianinfluenzaA(H7N9),involvingatourist,andareportofaMalaysiannationalwhosuccumbedtoMiddleEastrespiratorysyndromecoronavirus(MERS-CoV)infection.Inessence,preparednessand response capacity are prerequisites foreffective risk reduction and effective evidence-basedinterventionsforapotentialEVDoutbreakinMalaysia.

Acknowledgement

TheauthorswouldliketothanktheDirectorGeneralofHealthMalaysiaforhispermissiontopublishthisbriefcommunicationandtheWorldHealth Organization for all its support. Theauthorsaregratefultolocalhealthauthorities,allrelatedDivisionsintheMOHMalaysiaandotheragenciesinvolvedinrespondingtothisevent.

Funds

None.

Conflict of Interest

None.

Correspondence

DrWanNorainiWanMohamedNoorMBBCh(CairoUniversity),MPH(UKM)SurveillanceSectionDiseaseControlDivisionLevel6,BlockE10,ComplexEMinistryofHealthMalaysiaFederalGovernmentAdministrativeCentre62590Putrajaya,MalaysiaTel:+603-88834119Fax:+603-88886277Email:drwnoraini@gmail.com

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