Malaysia has seen a huge surge of COVID-19 cases this year, with cases hitting a daily high of over 20,000 cases at the end of August. We spoke to Professor Adeeba Kamarulzaman – who is Professor of Infectious Diseases at the Faculty of Medicine of Universiti Malaya, and also Chair of the COVID-19 taskforce at Universiti Malaya Medical Centre (UMMC) – on her experience ensuring infection control at the hospital over the past year, as well as key lessons and learning points gleaned.
Q: In your view, what are the two or three key infection control measures that hospitals need to set in place to prevent Healthcare Associated Infection (HAI), or prevent cross-infections during an outbreak?
A: For me, it would be having a proper infection control team – one that is commensurate to the size, busyness or complexity of the hospital. Obviously, the more complex, the more multidisciplinary the hospital is, the more complicated infection control will be.
Secondly, they have to be well-trained in modern infection control. All the other things, like hand hygiene, ventilation control, isolation procedures will come in naturally if you’ve got a strong, well-informed infection control unit.
The hard part is that infection control is a specialty that needs to be “diffused” to every single person who works in the hospital. It is a different type of skill from say, engineering or pharmacy; it is a technical skill, but it is also requires other skills such as communication skills in order to try and convince people that they own the problem.
I think until recently, infection control is seen either as an appendage of the infectious disease unit or a requirement for accreditation. If you look at it, infection control should be as important as any other essential support services.
Fortunately, infection control is now more than a “nice to have” for Malaysian hospitals, because we have got the MSQH (Malaysian Society for Quality in Health) and also JCI hospital accreditation programmes, so I’m pretty sure every hospital has an infection control unit. But whether it is commensurate to the size and complexity of the hospital, and given the same respect, budget and resources as it should, is probably another matter.
Q: Where do you think your hospital is at in terms of infection control readiness? What are the strengths and the gaps?
A: We relied heavily on our infection control department to set up guidelines, for example on isolation and PPE procedures, where to place the COVID wards to minimise cross transmission between COVID and non-COVID patients, and so on, particularly in the early days when there were so many uncertainties.
We trained the entire hospital on these procedures, like how to don and doff PPEs, which PPE to wear when, and how to manage COVID-19 patients. When patients started to come in, the infection control unit was instrumental in contact tracing – for example, if there were positive cases who were already in the hospital, there were implications in terms of where the infection came from, and contact tracing had to be done for other patients and staff.
There were so many angles where infection control played a huge role at our hospital. Readiness has grown since we sprang into action in January 2020, when we started putting in guidelines, conducting training and so on. We were reasonably ready by the time patients started to trickle in.
In terms of gaps, I think ventilation is going to be a huge challenge, simply because the buildings are old. How we are going to meet some of the standards given the age of the buildings will be very challenging.
Another is in terms of crowding, because there are not many other public hospitals around us, and there is a large population in the vicinity of our hospital.
Q: Malaysia has seen several waves of COVID-19 cases. Did the surge in cases lead to shortage of isolation spaces? How did your hospital manage that issue?
A: Particularly for Ministry of Health (public) hospitals, I think isolation just went out the window. There was no such thing as single rooms with negative pressure (for patients).
For our hospital, (when we were full) we had the ability to say no, we are not taking in any more patients. We were able to cope because we are quite a large hospital, and also because we decanted patients to private hospitals, and completely stopped all elective surgeries. We still managed to maintain single rooms for COVID patients, although negative pressure rooms were maxed out. Our hospital consists of four towers, and the entire main tower held only COVID patients, with the rest of the patients moved to the other towers.
Q: Over the past year, what were some key lessons you or the hospital learned in terms of infection control? How would that change the recommended infection control procedures moving forward?
A: I would say number one would be teamwork, and number two, making everyone realise that infection control is not just the problem for the infection control department and staff, that everybody should own infection control. Number three, communications, and training; and number four, resource.
Infection control should be there to support, guide and train but not to police.
I think even till now, a lot of people don’t necessarily see the connection between infection control, overuse of antibiotics and their patients getting multi-drug resistant infections.
As for changes in procedures, we have adapted the types or the levels of PPE that need to be used for different procedures. What we wanted to avoid at our hospital was people thinking that testing of patients is going to keep them safe, rather than wearing the right PPE.
With my HIV background, I tried to explain that you have to kind of assume that every patient may have COVID, in the same way that throughout my career, I assume that every patient may have HIV infection. This way, when you are managing patients, you would do the right thing or take the right precautions, like not recapping needles, wearing gloves when taking blood and so on. If we do routine mass SARS-COV2 testing – even if the results are negative, it could be a false negative test and if you are doing a high risk procedure, there is still a risk if you are not adequately protecting yourself with the right PPE. That message was difficult to get through.
Q: Could you share some stories or experiences that were memorable for you over the past year?
A: There were plenty of positive experiences. When we got really busy, everybody came together, from different disciplines. Even the surgeons helped to do ward rounds and look after patients.
But a negative experience would be when we just could not rationalise with certain teams in terms of the measures that they should do to keep patients, staff and themselves safe. They insisted on going completely overboard and have these irrational extra procedures, but at the same time, they would let their guards down in areas where we think they should do more. It got difficult when they think they know best, but we know that they are not doing it correctly. I had to step in as chair of the COVID taskforce.
But this happened last year when there were a lot of uncertainties. A lot of what I’ve described are actually personal anxieties on behalf of our colleagues, fears of getting COVID or bringing it back to their family, these fears are not expressed so they act up in all kinds of ways.
I think what has really made a big difference was vaccination. With the vaccine rollout, and people realising that it is protective and the risk of severe disease is low, and also with a better understanding of the disease, that anxiety and tension was reduced.
And of course, as we got better doing what we did, even with the huge outbreak this year things were a lot calmer.
About Professor Dato’ Dr Adeeba Kamarulzaman
Professor Adeeba Kamarulzaman is a Professor of Infectious Diseases at the Faculty of Medicine of Universiti Malaya, and formerly Dean of the faculty. A prominent infectious diseases expert who currently serves as a Member of the World Health Organization Science Council, she chairs the COVID-19 taskforce at Universiti Malaya Medical Centre. She is also President at the International AIDS Society, and Director at the Centre of Excellence for Research in AIDS (CERiA) in Malaysia. Professor Adeeba is a graduate of Monash University and trained in Internal Medicine and Infectious Diseases in Melbourne, Australia.