7th issue of CRC HKL Newsletter 2020

CRCHKL E-NEWSLETTER ISSUE 7 2020
CLINICAL RESEARCH CENTRE
HOSPITAL KUALA LUMPUR
HEAD OF UNIT
DR. HJH SALINA ABDUL AZIZ
DEPUTY HEAD OF UNIT
DR KARINA KOH
EDITOR-IN-CHIEF
DR NOOR HIDAYU WAHAB
EDITORIAL COMMITTEE
DR NOR ALIYA AYUB
DR PREM A/L W.P.VENUGOPAL
DR NIK NUR ELIZA MOHAMED
DR NUR AISYAH ABDUL RAHIM
HOSPITAL RESEARCH
REVIEW COMMITTEE
DR MOHD AZIZUDDIN
AMIR SHARIFFUDDIN
DR RAJ KUMAR A/L SEVALINGAM
CIK SITI SALEHA ADNAN
CLINICAL RESEARCH OPERATION
DR LEE JEN VEN
DR NUR AISYAH ABDUL RAHIM
DR VARAALAKSHMY
A/P GOKILAVANAN
RESEARCH QUALITY
DR NOOR HIDAYU WAHAB
DR NOR ALIYA AYUB
TRAINING & SKILLS DEVELOPMENT
DR DURATUL’AIN MOHD NAZRI
DR NADIAH ISMAIL
DR PREM A/L W.P.VENUGOPAL
PROMOTION AND COLLABORATION
DR NIK NUR ELIZA MOHAMED
DR SITI ZUBAIDAH OTHMAN
ADMINISTRATIVE
SISTER AZURA RAMLI
EN. MOHD HAFIZ
EN. MOHD IKRAM ZAKI
PN. NURUL HAZWANI AIZAN
EN. MULYADI RAMLI
CONTENTS
Editor’s Note 3
COVID-19, The Worst Pandemic in The
21st Century 5
Economy and Psychosocial Impact of
COVID 19 6
Actions by The Malaysian Government
to Combat COVID-19 8
COVID-19 Vaccines:
Ethical Conundrum 11
Impact Of COVID-19 on Clinical
Research: Challenges and Opportunities 14
Zulu Team Hospital Kuala Lumpur:
Isopod (Isolation Pod) User
Training and Retrieval 17
Mass Triaging and Retrieval of
COVID-19 Patients 21
Role of Modified Snorkeling Mask
NIPPV Device In COVID-19 and
SARI Patients 24
CRCHKL COVID-19 Journey 26
Research Poster 30
Publication by HKL Staff 2020 32
2020 Training Activities 46
Upcoming Courses in 2021 49
References List 51

PAGE 3

PAGE 4

PAGE 5
COVID-19
The Worst Pandemic
in The 21st Century
In December 2019, number of cases
of pneumonia caused by an unknown etiology
had been observed in the city of Wuhan, subse-
quently spread across Asia and the world like
wildfire. On January 7, 2020, the Chinese au-
thorities identified a novel coronavirus (nCoV)
as the cause of this severe pneumonia disease,
and the identification of nCoV was confirmed
by the WHO on January 12, 2020 (Secon et al.,
2020; Wu YC et al,.2020). By the end of Janu-
ary 2020, this disease was declared as a public
health emergency of international concern and
subsequently declared as pandemic on the
11th
of March 2020 by the WHO (Meckenzie
and Smith,.2020). The pathogen of the outbreak
was identified as a novel beta-coronavirus,
named 2019 novel coronavirus (2019-nCoV)
and this virus remind us the terrible memory of
the severe acute respiratory syndrome (SARS)
in 2003 and Middle East Respiratory Syndrome
(MERS) in 2012 caused by another beta-
coronavirus (Wu YC et al,.2020; Shah et
al,.2020).
The novel Coronavirus (nCoV) is an
enveloped, positive single-strand RNA virus. It
belongs to the orthocoronavirinae subfamily, as
the name, with the characteristic “crown-like”
spikes on their surfaces (Wu YC et al,.2020;
Shah et al,.2020). This virus falls under genus
beta-coronavirus. The genus beta-coronavirus
can be divided into several subgroups; nCoV,
SARS-CoV, and bat SARS-like CoV belong to
Sarbecovirus, while the MERS-CoV belongs to
Merbecovirus. Several studies have strongly
suggested that bats were the main host of this
coronavirus, as the whole genome-wide nucleo-
tide sequences of the nCoV were 96% identical
to bat coronavirus (Shah et al,.2020). Consump-
tion of infected, raw or semi-cooked meat can
lead to the transmission of the virus. COVID-19
recognized as zoonotic disease where an animal
virus undergoes mutations that permit it to in-
fect and replicate inside the human body where
it spreads rapidly through the human population
(Elengue,.2020). The major modes of transmis-
sion are from the respiratory tract via droplets
and indirectly via fomites and to a lesser extent
via aerosols.
For diagnosing COVID-19, early
diagnoses were largely based on clinical, travel
and exposure history of a patient return from an
epidemic area and nonspecific laboratory find-
ings as specific tests were not yet available
during the first 3 to 4 weeks of the outbreak.
Detection of the virus has been based on detec-
tion of the viral RNA by PCR, with various
assays directed particularly at the envelope (E),
RdRp, spike protein (S), and nucleocapsid (N)
genes (Meckenzie and Smith,.2020). COVID-19
symptoms are manifest usually as fever, dry
cough and tiredness. These symptoms appear
similar to common influenza, but the spread is
way far speedier. Despite its low fatality as
compared with SARS, its high infectibility has
led to a contagion of fear worldwide (Umair S et
al,.2020). The commonest clinical features are
fever with a respiratory illness, several studies
have reported fever in 80% to 99% of cases, dry
cough in 48% to 76% of cases, fatigue or myal-
gia in 44% to 70% of cases, and dyspnea in 30%
to 55% of cases (Meckenzie and Smith,.2020).
Apart from that, some infected individuals may
have mild symptoms like headaches, muscle
pains, runny nose, sore throat or diarrhea while
some patients may suffer from severe pneumo-
nia, organ failure, acute respiratory tract infec-
tion and septic shock, which can lead to death.
However, there are some infected people with-
out any symptoms which is called asymptomatic
carriers. There are 5 clinical stages of COVID-
19;Stage 1-asymptomatic, Stage2 - symptomatic
and no pneumonia, Stage 3-symptomatic and
pneumonia, Stage 4-symptomatic, pneumonia
and supplemental oxygen required, Stage 5-
critically ill with multiorgan failure
(Elengue,.2020). Severe infection and high
mortality are higher in older populations and
possibly in those with preexisting clinical illness
such as diabetes, hypertension, cardiovascular
disease, and malignancies (Meckenzie and
Smith,.2020).
Currently, there is no validated treat-
ment for COVID-19. The main strategies are
symptomatic and supportive care. However,
there are numbers of therapeutics under investi-
gation with some undergoing clinical trials in
China and elsewhere. Early interest focussed on
the HIV protease inhibitor combination lop-
inavir/ritonavir, a new broad-spectrum antiviral
agent called remdesivir, which has shown prom-
ising activity against MERS-CoV in animal
models, and possibly chloroquine. Combina-
tions of these with interferon-β and/or ribavirin
are being trialled, while other groups are look-
ing at a range of other antivirals, convalescent
plasma, and monoclonal antibodies (Meckenzie
and Smith,.2020).
The pandemic may seem to have
gone on forever. As we approach the end of
2020, it is easy to lose sight of how much pro-
gress science has made over the past 1 year.
Since January, scientist have gained a far
better understanding of COVID-19, and have
develop vaccines to battle the infections. This
COVID-19 vaccine development seems the only
hope that human being can rely on. The promis-
ing vaccines, better testing and treatment and
also greater knowledge we now have hopefully
can control the pandemic far better by early of
2021.
By Dr. Nor Aliya Ayub, Dr. Prem A/L W.P. Venugopal
Clinical Research Centre Hospital Kuala Lumpur.

PAGE 6
ECONOMY AND
PSYCHOSOCIAL
IMPACT OF
COVID-19
To slow the spread of COVID-19,
most countries in the world have implemented
regulations that require social distancing, the
closing of non-essential businesses, travel re-
strictions and, in many cases, stay-at-home or-
ders. Human interactions that drive the econo-
my, such as working together in enclosed areas
and enjoying entertainment activities, have been
discouraged, restricted, or banned altogether
(Fitzgerald D.A., 2020). Although these
measures are necessary for public health, recent
evidence suggests that COVID-19 has severely
demobilized the global economy. It has been
estimated that since World War II, the average
economic recession results in an increase in
unemployment of around 2% (Fernandes N.,
2020). Some of the experts are even saying that
human civilization has not faced such an unprec-
edented emergency after the World War-II
(Chakraborty I, Maity P, 2020). Lockdown due
to COVID-19, directly affect the Gross Domes-
tic Product (GDP) of each country in the major
economics. According to World Trade Organiza-
tion (WTO) and Organization for Economic
Cooperation and Development (OECD) have
indicated COVID-19 pandemic as the largest
threat to global economy since the financial
emergency of 2008–2009.
Many of the affected countries have
decided to undergo complete lock down in order
to restrict further transmission of the disease in
the community. Major international flights and
also all types of business transports have been
deferred amid different countries. In almost all
the COVID-19 stricken countries, entire educa-
tional, commercial, sports and spiritual institu-
tions are closed. Industries are suffering a lot as
many of these excepting those related to essen-
tial amenities, are closed for a long duration of
time. Production level has gone very low. People
belonging to the tourism are also facing utmost
difficulties. Economy of many so-called power-
ful countries are now facing the threat of high
inflation and increasing unemployment as a
result of lack of productivity and excessive ex-
penditure for the treatment and rehabilitation of
the COVID-19 victims and their families
(OECD Interim Economic Assessment, 2 March
2020).
In Malaysia, the massive and ongoing
outbreaks of this virus have become a serious
threat with profound consequences for the econ-
omy and financial markets as a whole. The fi-
nancial market is predicted to collapse, with the
chance of a new global recession (Majid,
M.,2020). The sudden enforcement of the MCO
by the government put various sectors of the
economy in jeopardy. According to AmBank
Group chief economist Anthony Dass, direct
damage caused by the virus can be seen in the
tourism and travel industries, manufacturing,
construction, mining, and agriculture, with many
workers being laid off and others being placed
on unpaid leave (Murugiah, 2020). The forced
closure of businesses, mainly the small and
medium sized enterprises (SMEs) and services,
could probably lead to permanent shutdowns and
many losing their jobs, as well as individuals
going bankrupt (Cheng, 2020). The Prime Min-
ister of Malaysia Tan Seri Muhyiddin Yassin has
particularly stated that the nation's tourism in-
dustry has been crippled, with an estimated loss
of RM 3.37 billion in the first 2 months of the
year (Dzulkifly, 2020). The Visit Malaysia 2020
(VM2020) campaign that aimed to attract 30
million tourist arrivals has also been cancelled
due to COVID-19 crisis. Malaysian government
estimated the VM2020 campaign to attract 30
million tourists and revenues up to RM 100
billion. However, with COVID-19 arises, it
obviously has decreased the number of visitors
and revenue for the whole year of 2020.
(Shakeel S, 2020).
As the COVID-19 pandemic drags on
globally, there is little doubt that it is taking a
lasting toll on the physical and mental health of
almost all people. The price of isolation and a
sense of societal obligation to assist may inad-
vertently include reluctance to bring the unwell
for medical assessment where the risks of medi-
cal review in the community or hospital can be
over-emphasised leading to late diagnoses with
very unwell people (Lazzerini M,2020). The
much-heralded substitute for face to face clinical
consultations has been the use of web-based
platforms or telephone consultations, but whilst
helpful for routine follow-up consultations, they
do have significant limitations for new or chal-
lenging diagnostic cases as they lack the ability
for physical examination. Moreover, the ability
to readily access routine investigations has also
been lost with the concerns about infection risk,
albeit mainly extrapolated from valid concerns
in the care of adults and children (Fitzgerald
D.A., 2020).
By Dr. Noor Hidayu Wahab
Clinical Research Centre Hospital Kuala Lumpur

Psychological consequences caused
by COVID-19 pandemic are enormous. In May
2020, the United Nations Secretary General
issued a message that the COVID-19 pandemic
had resulted in massive mental suffering and
called for actions. Distress, anxiety, depression,
and insomnia are relevant mental health disor-
ders due to their prevalence during COVID-19
outbreaks (Kang L, 2020). Lockdowns or quar-
antines are hostile experiences that can cause
severe financial stress due to loss of employ-
ment; social disorders such as social withdrawal,
cyberbullying, alcohol misuse, and addiction
and mental health issues such as suicide
attempts and depression (Reger, M.A., 2020).
People those in quarantine experience monoto-
ny, aloneness, irritation, worsening anxiety, and
mental distress. COVID-19 has been repetitively
labelled as a killer virus, mainly on social me-
dia, which has prolonged feelings of perceived
threats and uncertainty.
Fear and anxiety towards COVID-19
could potentially be overwhelming and hence
heighten the mental stress towards oneself and
society. This fear and anxiety are compounded
by social distancing as individuals want the best
of both worlds which is to be connected, yet to
not contract the ongoing coronavirus infection.
However, social distancing could disrupt the
social rhythm, by depriving one's regular coping
mechanisms with stress – hence putting mental
health at stake. According to the American
Psychiatric Association (APA), about 62% of
Americans are suffering from symptoms of
anxiety, which is related to COVID-19 and 59%
feels that the virus is greatly impacting their day
-to-day lives (Canady, V.A.).
Losing job in many people as an
economic consequence of COVID-19 brings in
feelings of uncertainty and insecurity - which
eventually disrupts mental health, leading to
feelings of anxiety and depression. The financial
burden hitting the population in Malaysia could
further escalate with individuals coping by
drinking alcohol and taking illicit substances
which then give further rise to multiple other
disorders such as alcohol use disorder and so on
(Hemavathi, S, 2020). Pandemics may also
negatively impact the poor and vulnerable
populations, and especially patients with serious
mental illness (Druss, B.G.). People with pre-
existing mental illnesses suffer a greater risk of
relapses, owing to fear, anxiety and social
rhythm disruption. Furthermore, social
distancing forces an individual to stay at home
for an extensive period. If the individual is
already living in a pre-existing toxic home
environment, spending more time at home could
be extremely stressful. The Women’s Aid
Organisation and Talian Kasih reported an
increment of 44% and 57% respectively in
contacts after the government-issued Movement
Control Order (MCO), for which domestic abuse
is one of the reasons cited (Lee, H.,2020).
Besides the general population, health
care workers on the front line are also at risk of
developing psychological distress while
managing patients with COVID-19. The long
working hours under uncomfortable and stress-
ful conditions may jeopardize their psychologi-
cal well-beings as well as their morale and work
performance (Waleed et al., 2020). Apart from
the social pressures faced at home and in the
society due to the implementation of MCO,
these critical frontliners are also at high risks of
to be exposed to serious mental health issues
resulted in symptoms such as being stressful,
severe depression, decline of work motivation,
fatigueness, and over-anxiety (Jianbo et al.,
2020)
Despite of all the negative impact
towards human lives, COVID-19 pandemic
gives outstanding environmental effect. As an
inevitable consequence of global warming,
environment pollution has become a big issue of
the present day. But, due to the unusual outbreak
of COVID-19, almost every big and small cities
and villages in the affected countries, are under
partial of total lockdown for a long period of
time ranging from a few weeks up to a few
months. Due to non-functioning of industries,
industrial waste emission has decreased to a
large extent. Vehicles are hardly found on the
roads resulting almost zero emission of green-
house gases and toxic tiny suspended particles to
the environment. Due to lesser demand of power
in industries, use of fossil fuels or conventional
energy sources have been lowered considerably.
Ecosystems are being greatly recovered. Ozone
layer has been found to have revived to some
extent. The pandemic has displayed its
contrasting consequence on human civilization,
in the sense that, on one hand it has executed
worldwide destruction, but created a very
positive impact on the world environment on the
other hand (Chakrabortya, I, 2020).

PAGE 8
ACTIONS BY
THE MALAYSIAN
GOVERNMENT TO
COMBAT COVID-19
Malaysia's recent success in control-
ling the spread of COVID-19 has been acknowl-
edged by the WHO and it is closely related to
immediate and proactive action taken by the
Ministry of Health (MOH) including enforce-
ment of the different phases of Movement Con-
trol Order (MCO); alliance with various organi-
sations, including non-governmental organiza-
tions (NGO) to host fundraising as well as
providing personal protective equipment for
frontlines (Minhat and Shahar K., 2020).
Similar to the high-income nations,
low and middle-income countries (LMICs) also
responded to COVID-19 by implementing vari-
ous public health interventions at population-
level, including strict nationwide lockdowns and
physical distancing. These interventions have
generally been successful in preventing over-
loading of health systems, particularly in LMICs
where the risk of disease transmission is high
due to high density of communities and interac-
tions; inadequate knowledge of disease preven-
tion; under-resourced of public health systems;
restricted access to healthcare facilities, espe-
cially rural areas; and relying on mostly out-of-
pocket payment (Chowdhury et al., 2020).
Among the earliest actions taken by
the MOH to prevent this virus transmission is
by enforcing health screening at all points of
entry, placing thermal scanners to enhance fever
detection among tourists and/or local returning
from abroad. People arriving from countries
with high cases of COVID-19 have been
screened, identified and quarantined in separate
quarantine areas. These precautions have also
been extended to airline crews as well as to
MOH staffs (Shah A et al., 2020). Initially, the
Ministry of Health has implemented public
health interventional strategies. A rapid reverse
transcriptase-PCR test on patients and relations
was developed, used and provided to other gov-
ernment hospitals and medical laboratories, and
management guideline were developed (Umair
S et al., 2020). Specific hospitals were then
identified and assigned to handle COVID-19
cases as a measure to isolate the patients and
prevent them from affecting others. Subsequent-
ly, other ministries such as Ministry of Educa-
tion (MoE), Ministry of Defence (MinDef) and
private hospitals collaborate to accommodate
the growing number of COVID-19 cases. As of
31 October 2020, there are 46 designated hospi-
tal in Malaysia to handle and manage COVID-
19 case and there are 118 screening centres for
COVID-19 (Garis Panduan Pengurusan COVID
19 di Malaysia No.5., 2020).
To effectively control the current
COVID-19 situation, the Malaysian Govern-
ment has implemented different levels of
Movement Control Order (MCO) in the areas
with the presence of COVID-19 cases, depend-
ing on the number of active cases in the area.
Initially, the government imposed a 2-week
MCO starting from 18 to 31 March, which was
extended to 14th
April, then to 28th April until
3rd
May. As the curve flatten, the government
imposed Conditional Movement Control Order
(CMCO) from 4th
till 9th
June 2020 then
Recovery Movement Control Order (RMCO)
from 10th
June till 31th August 2020 (Flanders
Trade, 2020). On October 9, 2020, Malaysia
Health director-general Tan Sri Dr Noor
Hisham Abdullah states that Malaysia entering
its third wave of COVID-19 (Bernama, 2020),
most of the cases mainly concentrated from
Kedah and Sabah. The Malaysian Government
has implemented Enhanced Movement Control
Order (EMCO) on the areas with a high number
of COVID-19 cases; Targeted Enhanced
Movement Control Order (TEMCO) to a much
smaller space with a high number of COVID-19
cases, such as a residential complex or an office
building; and Administrative enhanced move-
ment control order (AEMCO) applies similarly
to specific high-risk areas but with fewer
restrictions (Flanders Trade, 2020).
For community-based control
measures, outdoor limits were also
implemented, whereby only one resident from a
family was permitted to leave at one time and
within 10 km of the house. Checkpoints were
set up to track temperatures at the access point
of homes, pharmacies and grocery stores. For
better prevention, Malaysian citizens were
banned from leaving the country, and foreigners
were also not permitted to enter the country.
By Dr. Nor Aliya Ayub

PAGE 9
'Resolving, resilience, restarting, recovering, revitalizing and
reforming' is a new norm for the citizens of Malaysia. The Malaysian
Government's six-step strategy is to resolve the effects of COVID-19 and
to ensure that the country emerges stronger despite this outbreak. Using
this six-step strategy, Malaysians are seeking to adhere with new rules of
operating procedures (SOPs) to avoid another wave of infections in the
country and to revive the economy in stages (The Straits Time, 2020).
In terms of public awareness and acceptability of this pandem-
ic, the Ministry of Health always be transparent in handling the pandem-
ic by providing sufficient and up-to-date information to the public
through various platforms including the Official MoH website, social
media such as facebook and telegram; called Crisis Preparedness and
Response Centre (CRPC) page, Kementerian Kesihatan Malaysia
(KKM) page, and CRPC KKM Telegram. MOH also provide communi-
ty education and awareness programmes regarding COVID-19 in a sim-
ple diagram and infographic via website and social media to reach public
easily. They also conducted daily press conference or recordings and has
published related news on COVID-19 to increase public engagement and
ensure public awareness and access to reliable information (Shah A et
al., 2020). Besides that, the media also plays an important role in active-
ly spread the information and boost up the frontliner’s spirit in handling
and managing this outbreak. Hashtag #stayhome, #kitajagakita are fre-
quently appeared in radios and television (Minhat and Shahar K., 2020).
Non-governmental organizations, as well as prison inmates, started to
produce personal protective equipment for frontliners. Various organiza-
tions hosted fundraising events to provide essentials mainly to hospitals
(Shah A et al., 2020).
As at October 31, 2020, there have been 1,182,747 deaths
around the world (WHO, 2020) and the numbers keep growing without
no proven definite treatment or vaccine for this disease. Hence, National
Institute of Forensic Medicine (IPFN) Malaysia has produced a guideline
on management of the dead for all COVID-19 suspected or confirmed
deaths within the hospital as well as from outside the hospital. This
guideline consists of various sections including guidelines on body
transport from Emergency Departments or wards to the mortuary, post-
mortem examination, handling of the body and religious/ritual body
preparation and disposal. They also provide training to the Royal Malay-
sian Police (PDRM) on proper hand hygiene and washing, donning and
doffing of the standard full personal protection equipment (PPE). A
severe pandemic is the incident most likely to create a need for an exces-
sive death number contingency planning. A COVID-19 Centralized
Body Facility is a temporary mortuary centre for all COVID-19 deaths
within a country. This centre adopting the concept of a quarantine centre
to locate COVID-19 patients if their numbers become overwhelming,
there is a need to relocate the remains of all decedents who were infected
with COVID-19 to a temporary mortuary centre when mortuaries are
overloaded (Khoo L,. 2020).
To help Malaysian who are financially affected by COVID-19,
the government introduced an emergency stimulus package, one of the
largest in the world, to stabilize economic development, promote invest-
ment and foster business activity (Umair S et al., 2020). The PRIHATIN
Package has been one of the beneficial initiatives announced by the gov-
ernment, followed by drastic measures of a 6-month moratorium offered
by Bank Negara Malaysia to reduce the financial impact. Credit card-
holders can choose to convert outstanding balances into term-loans. The
corporate sector can restructure their bank loans. Other than that, Minis-
try of Heath also setting up the special fund known as COVID-19 fund,
to help for those particularly financially affected due to quarantine pro-
cess. Through this fund, RM 100 was given daily to who had no source
of income throughout the quarantine and treatment processes, this fund
also used to cover medical expenses such as buying crucial equipment
and other supplies (Shah A et al., 2020). IRB also offering tax deduc-
tions for cash and item donations to help the affected communities.
In terms of mental health support, Ministry of Health, Malay-
sia has provide guideline about Mental Health and Psychosocial Support
in COVID-19 in Annex 33 (Garis Panduan Pengurusan COVID 19 di
Malaysia No.5 b, 2020). Mental Health and Psychosocial Support
(MHPSS) refers to any type of local or outside support that aims to pro-
tect or promote psychosocial well-being or prevent or treat mental disor-
ders. This support may be provide to all public that affected especially
Healthcare workers (HCW), person under supervision (PUS) as they are
worry of possibility that their family members are infected. Support may
include interventions in health, education, or interventions that are com-
munity-based.

PAGE 10

COVID–19 VACCINES :
ETHICAL CONUNDRUM
At present, there are several clinical
trials being conducted to identify the safest and
the most effective vaccine for COVID-19. In
November 2020, COVID-19 vaccine developed
by Pfizer and BioNTech had reported prelimi-
nary data in offering 90% protection against
COVID-19. In addition, a United State based
company, Moderna has also announced that its
vaccine candidate is capable to offer 94.5%
protection against COVID-19. These two vac-
cines are reported as mRNA vaccines which
would be required to be stored at -70 and -20
Celsius. (British Broadcasting Corporation,
2020.) Other promising vaccines include the
vaccine being developed by British pharmaceu-
tical company AstraZeneca in collaboration
with the University of Oxford and Sputnik
vaccine which being developed in Russia.
By definition, a vaccine is a biologi-
cal preparation that provides active acquired
immunity to a particular infectious disease.
(IACT Health, 2020) The development of any
vaccine must undergo a series of standardized
clinical development. In general, the develop-
ment cycle of a vaccine includes the explorato-
ry stage, the pre-clinical stage, the clinical
development, the regulatory review and ap-
proval, manufacturing and quality control.
(Centres for Disease Control and Prevention,
2020) The clinical development is a three-
phase process. During the phase one study, a
small group of healthy volunteers would re-
ceive the trial vaccine. In phase two, the num-
ber of study volunteers are expanded and the
trial vaccine is given to a diverse group of
volunteers. During the phase three, it would be
a large-scale study with the main objective to
confirm the effectiveness, to establish the trial
vaccine safety profile and to compare it with
the placebo or a comparative vaccine product.
At present, without the proven effec-
tive treatment against the infection, the devel-
opment of COVID-19 vaccine had been the
utmost priority in combating the pandemic
which had affecting billions of lives world-
wide. With the urgency and the dire needs of
the vaccine, the development of COVID-19
vaccine had been relatively much shorter as
compared to other vaccines which usually take
years to be developed. However, there are a
number of ethical considerations pertaining to
the COVID-19 vaccine development. The ethi-
cal principles on COVID-19 vaccine develop-
ment could be discussed based on the four main
principles of biomedical ethics introduced by
Beauchamp and Childress namely autonomy,
beneficence, non-maleficence and justice.
The study volunteers who had
agreed to participate in the COVID-19 vaccine
clinical trials must do so in their own freewill.
Informed consent is a key process in ensuring
the autonomy of each study volunteer is re-
spected. A legally and ethically acceptable
informed consent must consist of adequate
provision on information, volunteer compre-
hension on the clinical trial process involved
and voluntariness from the study volunteer.
Hence, these three elements must be present to
validate the autonomy of the study volunteers.
Firstly, essential and relevant information per-
taining to the study must be conveyed to the
volunteers adequately. Some of the important
information include the study objectives, the
anticipated risks and benefits, the study proce-
dures and the details on the trial drug. Second-
ly, the methods and the context on how the
information is conveyed to the study volunteers
must be in organised and professional manner.
The study volunteers must be allowed the op-
portunity to inquire for clarification to enhance
their understanding on the study involved.
Lastly, the study volunteers must be able to
participate in the study voluntarily without any
form of coercion or undue influence. However,
inducement might be considered as undue in-
fluence if the study subjects are vulnerable in
terms of socio-economic status or under the
higher authority such as being a prisoner.
By Dr. Nik Nur Eliza Mohamed

The essentiality of the vaccine is
one of the main considerations of the ethi-
cal principle of beneficence. The urgency
and the necessity of the vaccine is mainly
to reduce the associated morbidity and
mortality of the COVID-19. To date, more
than 1.4 million death with over 61 mil-
lion COVID-19 cases had been reported
worldwide. Malaysia is being hit with the
local third wave of COVID-19 pandemic
with the total over 60,000 reported cases
with more than 300 COVID-19 mortalities
recorded to date. (Wordometers, 2020) In
addition, travel restrictions and disrup-
tions in terms of economic, education,
healthcare access, mental health are some
of the devastating effects from the pan-
demic. Thus, the argument for essentiality
of the COVID-19 vaccine is very much
supported with the quantum of disruption
and destruction caused by COVID-19
throughout the whole world. In addition,
the sense of safety and reassurance espe-
cially among the high-risk communities
would be restored to pre-pandemic with
the availability of the vaccine. For person-
al or individual reasons, many study vol-
unteers would cite the reason being altru-
ism for their motivation to be one of the
COVID-19 study volunteers.
Non-maleficence can be trans-
lated to “do no harm” as it is closely asso-
ciate to the Latin phrase “maxim primum
non nocere”. In the context of clinical
trials, it would be almost impossible for
any clinical trials to be conducted without
any risks or harm to the study volunteers.
The ‘harm’ subjected to the human volun-
teers might be directly or indirectly caused
by their participation in the clinical trials.
However, the risks or harm in any clinical
trials must be minimised to protect the
safety and well-being of the study volun-
teers. In the case of a vaccine study, the
‘harm’ is possibly caused with the healthy
volunteers being deliberately exposed and
infected with the pathogens. In a human
vaccine challenge study, it involves the
intentional infection of research partici-
pants and can accelerate or improve vac-
cine development by rapidly providing
estimates of vaccine safety and efficacy.
(Eyal et al, 2020) This might raise an
ethical concern on the potential devastat-
ing adverse event on the volunteers who
participate in the clinical trial. This is
compounded with the fact that COVID-19
infection has no proven clinical treatment
so far which potentially might lead to
morbidity and mortality of the volunteers.
(Jamrozik and Selgelid; 2020) The recent
example of the reported death of a volun-
teer in a clinical trial of the COVID-19
vaccine developed by AstraZeneca and
Oxford University had been a public inter-
est and had raised some ethical concerns
regarding the adverse events which poten-
tially harm the study volunteers.
In any clinical trial, the benefits
to the society and the study volunteers
should outweigh the risks to the volun-
teers. The risk stratification and assess-
ment should be conducted by independent
bodies such as the ethical committees to
prevent the element of biasness. Risk
minimization and mitigation plan should
be in place to reduce the harm towards the
volunteers. If there is any imminent health
hazard such as worsening health condition
of the volunteers, the volunteer should be
withdrawn from participating further in
the study. Another ethical consideration
which must not be overlooked among the
altruistic volunteers who sign up for po-
tential challenge studies amidst the global
COVID-19 pandemic is that they may also
suffer from misconception and overconfi-
dence that the research will provide sub-
stantial future societal benefit. (Dawson et
al, 2020) This is substantiated with the
fact that there is always an element of
uncertainty or failure amidst the journey
towards the vaccine development.

PAGE 13
The final ethics principle evolv-
ing around the development of the COVID-
19 vaccine is ‘Justice’. Two essential ele-
ments under ‘Justice’ would be non-
exploitation and relevance to the communi-
ty. For non-exploitation, the protection of
the rights, safety and welfare especially
among vulnerable human subjects such as
prisoners, those who are with lower socio-
economic status and persons with disabil-
ity. In terms of the relevance to the commu-
nity, local societal benefit of the vaccine
especially when the study volunteers were
derived from the community must be taken
into consideration. For example, the Afri-
can continent which is generally consist of
some of the low- and middle-income coun-
tries is statistically least affected by
COVID-19 as compared to other part of the
world. Thus, the decision to conduct any
COVID-19 related clinical trial among the
local community must be carefully consid-
ered.
The ethics committee functions as
independent body in which is authorized to
regulate and to monitor the conduct of any
clinical trials locally. The committee would
be responsible to do so by upholding the
requirements based on the Good Clinical
Practice. The main objective would be to
ensure vigorous scrutiny prior to the vac-
cine study approval to protect the safety
and well-being of the human volunteers
and future recipients of the vaccine. The
relevant clause in Good Clinical Practice is
stated in clause 3.1.1; An IRB/IEC should
safeguard the rights, safety, and well-being
of all trial subjects.” (Malaysia Guideline
for Good Clinical Practice, 2018) An up-to-
date publication by World Health Organisa-
tion entitled ‘Key criteria for the ethical
acceptability of COVID-19 human chal-
lenge studies’ would be an excellent refer-
ence for the local ethics committee to eval-
uate any local clinical trials for the
-19 vaccine studies.
What are the roles of the re-
searchers? They are tasked to conduct the
clinical trials as according to the Good
Clinical Practice. In addition, they must
ensure that the study volunteers are protect-
ed, data integrity is preserved and clinical
trial is conducted as according to the ap-
proved protocol. This is clear stated in
Good Clinical Practice clause 4.8.1 which
states ‘’In obtaining and documenting in-
formed consent, the investigator should
comply with the applicable regulatory re-
quirement(s), and should adhere to GCP
and to the ethical principles that have their
origin in the Declaration of Helsin-
ki.” (Malaysia Guideline for Good Clinical
Practice, 2018)
In conclusion, clinical trial is an
essential process in the advancement of
science. The ethics considerations based on
the four major ethical principles as dis-
cussed early could serve as an important
ethics framework in designing, monitoring
and conducting clinical trial related to
COVID-19. In the pursuit of vaccine crea-
tion and development, the safety and well-
being of the study volunteers must not be
compromised. Referring to the ICH GCP
clause 2.3 which has clearly stated that
“The rights, safety, and well-being of the
trial subjects are the most important con-
siderations and should prevail over inter-
ests of science and society.” (Malaysia
Guideline for Good Clinical Practice, 2018)
In another words, the volunteers must never
be sacrificed in the pursuit of any scientific
advancement. Nonetheless, when risks or
harm is almost to be fully avoided or eradi-
cated, measures must be taken to optimally
safeguarding the volunteers’ rights, safety,
and well-being.

PAGE 14
IMPACT OF COVID-19 ON
CLINICAL RESEARCH :
CHALLENGES AND
OPPORTUNITIES
The recent global public health cri-
sis, COVID-19 pandemic, has undoubtedly
created a massive threat on health system and
healthcare delivery worldwide. Clinical re-
search practice is no exception, with the un-
precedented situation causing tremendous
disruptions on both new and ongoing clinical
trials (EMA guidance, 2020). This is particu-
larly relevant for clinical research not directly
involved with COVID-19 management, and
those requiring participants’ access to clinical
sites.
Various organisations, agencies, and
authorities worldwide have recognised the
impact of COVID-19 pandemic on the conduct
of clinical trial hence, issued guidance for
industry, investigators, and institutional review
boards on how to manage clinical trials during
the pandemic while protecting the safety of
patients and healthcare workers. The key au-
thorities include the European Medicines
Agency (EMA), the U.S. Food and Drug Ad-
ministration (FDA) and United Kingdom’s
Medicines and Healthcare Products Regulatory
Agency (MHRA).
Some of the main challenges in con-
ducting clinical research during this pandemic
may arise from quarantines, site closures, hos-
pital restrictions, travel restrictions, interrup-
tions to the supply chain for the investigational
product and safety concern of trial participants
and site personnel (FDA guidance, 2020). This
is particularly the case when the Malaysian
government enforced a nationwide Movement
Control Order (MCO) on 18th
March 2020 to
curb the spread of the COVID-19 infection.
The MCO is imposed under the Prevention and
Control of Infectious Diseases Act 1988 and
well as the Police Act 1967 (MKN, 2020). The
above-mentioned challenges may lead to diffi-
culties in meeting protocol-specified proce-
dures especially for administering the investi-
gational product or adhering to protocol-
mandated visits and laboratory/diagnostic test-
ing (FDA guidance, 2020). Therefore, taking
this into account, both of the Malaysian regula-
tory body and ethics committee namely, the
National Pharmaceutical Regulatory Agency
(NPRA) and the Medical Research Ethics
Committee (MREC), respectively, recognised
that protocol modifications and unavoidable
protocol deviations may be required.
In Hospital Kuala Lumpur (HKL),
there is a total of 60 ongoing industry-
sponsored research (ISR) studies that are coor-
dinated together with Clinical Research Ma-
laysia (CRM). During the MCO period from
March until June 2020, most of the ISR studies
were able to proceed with minimal disruptions,
especially for oncology studies because conti-
nuity of treatment is crucial for patient safety
as it is either part of the standard of care or
trial protocol. However, there were 4 studies in
recruitment phase that the sponsors decided to
withhold in order to protect the safety of trial
subject and site personnel by minimising risk
of exposure to the COVID-19 infection. The
decision to continue or discontinue a study
should be made in accordance with the FDA
guidance, which called upon researchers and
sponsors to determine that the participant’s
safety, welfare, and rights is best served by
continuing the trial as per protocol or by dis-
continuing the administration of investigation-
al product or even participation in the trial
(FDA guidance, 2020). Aside from this, 3
studies had to postpone their subject visits in
view of travel restrictions and 1 study due to
trial subjects’ unwillingness to visit hospital
site during the MCO period which resulted in
an anticipated protocol deviation. Among all
of the ISR studies, 3 study protocols were
amended to allow the conversion of physical
visits into phone call assessments. In addition,
1 study decided to deliver the investigational
medicinal products (IMP) directly to trial par-
ticipants’ homes during the COVID-19 pan-
demic. These changes were implemented to
minimise risk of spreading or acquiring infec-
tion by preventing avoidable visits to study
site. Similarly, majority of the Clinical Re-
search Associate (CRA) visits for source data
verification (SVD) were either postponed or
conducted as remote monitoring via video calls
only when necessary. All of the changes men-
tioned above are in line with the EMA and
FDA guidance. Evidently, the disruptions
caused by COVID-19 has pushed stakeholders
toward remote monitoring technologies and
telehealth to make trials more patient-centric
while maintaining trial integrity.
By Dr. Nur Aisyah Abdul Rahim

PAGE 15
As for investigator-initiated research (IIR) studies, there
are a total of 207 studies registered under Clinical Research Centre
(CRC) HKL in 2020 compared to 259 studies in 2019, which is a
20% reduction. However, out of the 207 studies, 42 are COVID19-
related studies. The decline in the number of non-COVID19 IIR
studies may be attributed to the need for hospitals to prioritise clin-
ical activities in managing patients and staff affected by the pan-
demic (Lorusso, D. et al., 2020). For example, many HKL staff
from various departments were deployed to help the emergency
department, coronavirus mass screening area (CMSA), COVID-19
wards, quarantine centres and COVID-19 operational room. Con-
sequently, many investigators were pulled away from working on
clinical research to work in emergency medical care where the
pandemic threatened to overwhelm critical care resources (Van
Dorn, A., 2020). Undeniably, this pandemic has sparked great in-
terest in the disease, not only in HKL but also worldwide as evi-
denced by the 2995 COVID19-related clinical trials registered with
ClinicalTrials.gov (Van Dorn, A., 2020). The EMA guidance rec-
ognises that the authorities should give priority to any (new) clini-
cal trial application for the treatment or prevention of COVID-19
infection (EMA guidance, 2020). Therefore, it is fitting that
MREC has offered an expedited ethical review and approval for
any relevant COVID19-related studies to help increase the
knowledge in this research area.
With the global pandemic affecting more than 180 coun-
tries, efforts have been made to find possible life-saving treatment
to fight against this severe acute respiratory syndrome coronavirus
2 (SARS-CoV-2) infection. In March 2020, WHO launched the
world’s largest randomised control trial on COVID-19 therapeutics
called the Solidarity Trial. This international trial enrolled almost
12,000 patients in 500 hospital sites in over 30 countries, including
Malaysia, with HKL being one of the nine Ministry of Health
(MOH) hospitals involved (WHO News, 2020). Although the in-
terim results from this trial indicated that none of the treatment
regimens had significant effect on mortality and in-hospital course
among COVID-19 patients (WHO Solidarity Trial, 2020), the pro-
gress achieved by the Solidarity Trial shows that large internation-
al trials are possible, even during this challenging time.
Another major impact that COVID-19 has on our research
community is its influence on scientific meetings and conferences.
Undoubtedly, many research conferences have been cancelled or
postponed on an unparalleled scale (Lorusso, D. et al., 2020) in
order to comply to the standard operating procedure (SOP) espe-
cially during the MCO period. For example, the 13th
National Con-
ference for Clinical Research (NCCR), cleverly titled “Conference
of Very Important Disease (COVID)”, was conducted virtually for
the very first time including virtual viewing of scientific posters
submitted for evaluation. Similarly, training workshops and week-
ly Hospital Research and Review Committee (HRRC) board meet-
ings organised by CRC HKL were also done virtually whereas the
research consultation clinic (RCC) sessions were done either via
emails or phone call consultations. Although this pandemic has
caused tremendous disruptions to many of our previously planned
scientific meetings, it has also created an opportunity to explore
new methods of communicating and organising events using vari-
ous underutilised virtual platforms and online interactive tools.
It is unquestionable that the COVID-19 pandemic has
imposed many challenges in the conduct of clinical research.
Therefore, it is the responsibility of all stakeholders involved to
work together to continue their efforts in protecting the safety of
trial participants and site personnel, maintaining compliance with
good clinical practice (GCP), and minimising risks to trial integri-
ty. With this notion in mind, all parties should strive to continue
conducting high-quality clinical research even during this unprece-
dented era.
“In March 2020, WHO launched the world’s largest
randomised control trial on COVID-19 therapeutics
called the Solidarity Trial. This shows that large
international trials are possible, even during this
challenging time”

PAGE 16

PAGE 17
Introduction
The COVID-19 pandemic has taken
stage worldwide since it’s detection in Wu-
han, China in November 2019. It has taken
over the world in such a rapid pace, far more
threatening than expected, causing countries
to play ‘catch up’ to it; from preparedness,
detection, and treatment in order to curb the
rising number of cases. It has been putting
massive burden on governments, healthcare
workers and facilities at all levels. Infection
rate and fatalities were and is going up by the
minute, including the frontliner themselves.
Hospitals ran out of resources quickly thus,
the most efficient way is to work together and
use all sources in well-ordered manner. Re-
education in infection control, safety proto-
cols, equipment handling were implemented
to enhance treatment, ensure safety of all per-
sonnel and cater of those performing floor
managerial work. These are also essential to
curb infection from spreading. In the Hospital
Kuala Lumpur, we are proud that simulation-
based training done for COVID-19, is at par
with other countries overseas.
Section 1: Isopod User Training
Isopod is a portable device that
provides a negative pressure environment and
is used during the transportation of highly
infectious patients, namely COVID-191
. It
requires a specialised team that understands
the use of it and able to troubleshoot problems
within its environment once it is sealed2
. User
training is very essential for the safety of the
patient, healthcare providers, and general
public. We teach the principles of transporting
a ventilated patient with COVID-19 which is,
to prevent aerosolisation and minimising
spread at all times. We have a prepared check-
list for Isopod transportation to ensure that
complications can be prevented and managed
more efficiently during the highly stressful
period.
The training was originally lead by
Dr Umul Khair Mohamad who subspecialised
in Pre-Hospital Care & Disaster and was ech-
oed to others with similar interest. Up to date,
we had a total number of fifteen trainings that
were held since the pandemic started. We had
already trained 43 doctors (twelve Emergency
Physicians and 31 Medical Officers) and 39
allied health personnel. Methodology of teach-
ing include mini lecture followed by a simula-
tion-based training, visualisation and coopera-
tive learning. Teamwork is very important to
guarantee successful and safe patient
transport.
Isopod simulation training encom-
passes the important aspects of airway man-
agement during mobilisation from one ward to
another; in the same hospital or inter-
hospitals. Training includes clamp/
unclamping of endotracheal tube (ETT), pre-
paring and setting the ventilators (e.g not to
ventilate during standby mode). This is ex-
tremely crucial in order to prevent aeresolisa-
tion to transport staff and surroundings.
Breathing and circulation are managed by
allied health personnel whereby the monitors
and oxygen tank are placed in such a way that
it will not disrupt the lean process during
transportation. Infection control (donning and
doffing) are also integrated to prevent decon-
tamination. Apart from that, all members were
also being taught to debrief and perform post
mortem after each transfer is done.
Figure 1: A short lecture was given as an introduction before the hands-on session
ZULU TEAM HOSPITAL KUALA LUMPUR:
ISOPOD (ISOLATION POD) USER TRAINING AND RETRIEVAL
Dr Amira Farhana Abdul Khalil
Emergency and Trauma Department,Hospital Kuala Lumpur, Malaysia

Figure 2: The importance of managing the airway by the team leader is shown above as example
(during static and dynamic movement)
Figure 3: We demonstrated a proper placement of the isopod, oxygen, and all the monitoring equipment during patient
movement and inside the ambulance
Section 2: Isopod Retrieval
Zulu Team was started back in March 2020. It was devel-
oped as an initiative to assist the hospitals around Klang Valley for
transportation of ventilated COVID-19 patients, frequently to Hos-
pital Sungai Buloh which is Malaysia’s main COVID-19 hospital.
In addition to that, Zulu Team is also accountable for emergency
cases that take place in quarantine centres around Kuala Lumpur.
This team started of with 11 members (2 Emergency
Physicians, 8 allied health personnel). As the number of cases and
patient retrievals increase, the Zulu Team has expanded to seventy
members to date.
The Zulu Team are comprised of Outer Ring and Inner
Ring. These two components compliment each other in performing
safety checks and retrievals. The job scopes of each personnel are
as follows4
:
Outer Ring
This component consists of one Emergency Physician and one
Assistant Medical Officer.
Job:
• To clear transport pathway
• To receive and give instructions for transport direction
• To give and receive passover reports (X-ray films, patient med-
ical records and personal belonging)
• To counter check the safety aspects of the work process in
Inner Ring

PAGE 19
Inner Ring
i) Team Leader (Emergency Physician/
Medical Officer):
• To make sure ETT is secure at all
times
• Setting up the transport ventilator
• Exchange tubing to and fro
transport ventilator to ward ventila-
tor
• To gather all patients information
ii) Assistant 1 (Assistant Medical Officer
or Staff Nurse):
• To ensure the oxygen port in the
transport ambulance is compatible
with transport ventilator
• Assist in patient transfer between
bed and stretcher
• To apply monitoring devices on
patient (cardiac monitor, blood
pressure cuff and SpO2 prob)
• To ensure all equipment are safe
and functioning well
• To remind team leader to secure
ETT and administer IV Rocuroni-
um prior to transfer
• To aid in setting up the Isopod
• To ensure the ventilator is in
standby mode
• To double check safety
ii) Assistant 2 (Assistant Medical Officer
or Staff Nurse):
• To prepare medications that will be
used on patient (sedation, inotropes
and Rocuronium)
• To ensure safety line is functioning
• To make sure that infusion pumps
are function well
• To administer IV Rocuronium with
20cc flush prior to transferring pa-
tient from bed to isopod with EP/
MO instructions
• Double pumping
• To ensure vital signs are stable be-
fore single pumping
• To prepare gauze and sponge hold-
ing forcep to clamp ETT
• To switch on/off Isopod blower
Between 29th of March to 9th of
July 2020, a total of 54 patients were re-
trieved and directed to COVID-19 tertiary
hospital5
. These cases ranges from zero to
three patients per shift. Exponential rise
was noted during waves of the COVID-19
pandemic. The team members were trained
on how to manage complications during
patient transfer and how to troubleshoot
problems that arises on the spot.
Conclusion
Based on the daily COVID-19
cases that were reported nationwide, we do
not see any sign that this will be under
control soon. Thus, we need to strengthen
our capacity and capabilities to guarantee
that we are ready to perform our best dur-
ing the call of duty and as frontliners of
Malaysia.
Figure 4: (Left) The first Isopod training with Dr Sarah Shaikh Abdul Karim, Assistant Director of Central Region
Covid-19 Unified Command Centre in collaboration with the National Security Council (NSC). (Right) Isopod is in
ready-to-roll position

Figure 5: The team members are ready to go for patient retrieval
Figure 6: The team members after patient retrieval and transfer to dedicated COVID-19 hopital.
Figure 7: The team members post doffing

PAGE 21
COVID-19 pandemic warrants con-
sideration as a mass casualty incident (MCI) of
the highest nature. An optimal MCI/disaster
management should consider all four phases of
the so-called disaster cycle which are mitigation,
planning, response, and recovery1
.
The public health objectives at all stages of the
preparedness and response plan are to:
• Prevent outbreaks, delay spread, slow and
stop transmission.
• Provide optimised care for all patients,
especially the seriously ill.
• Minimize the impact of the pandemic on
health systems, social services, and econom-
ic activity2
.
The Malaysian Government and affil-
iated agencies with the guidance of Ministry of
Health has formed a structured planning and
response to COVID-19; from the implementa-
tion of Movement Control Order (MCO) to
Guidelines of COVID-19 Management in
Malaysia. On top of that, this also includes
setting up Low Risk COVID-19 Quarantine and
Treatment Centre (PKRC).
In response to this, Central Region
COVID-19 Unified Command Centre was estab-
lished with the help of the National Security
Council (MKN) and led by Selangor Health
Director Dr. Sha’ari Ngadiman. One of the many
tasks is to screen, triage and retrieve COVID-19
patients from the District Health Offices (PKD)
in Klang Valley. This operation of mass triaging
and arranging admission to COVID-19 dedicat-
ed hospitals are done in collaboration with hos-
pitals in the Klang Valley, especially Sungai
Buloh Hospital under the leadership of Dr. Sarah
Shaikh Abdul Karim; Consultant Emergency
Physician (Fellowship in Prehospital Care and
Disaster Medicine).
Patients with COVID-19 illness
should have close monitoring of vital signs ac-
cording to phases of illness and monitoring for
progression of disease. Without proper stratifica-
tion, deterioration could occur rapidly despite no
warning at the initial phase.
According to Tan Sri Dr. Noor
Hisham Abdullah (Director General of Health
Malaysia), the majority of COVID-19 patients
are asymptomatic or only having mild symp-
toms5
. Majority of the patients that were
screened are deemed stable and categorised as 1
and 2. Patients from these categories will be sent
to PKRC. These patients do not require around
the clock and extensive monitoring of their con-
dition. Less man power are required to run these
centres. This will certainly help ease the loads
off the main hospitals. PKRCs are also utilised
for step down care from initial admission to
hospitals. Even though PKRCs are not originally
health centres, they are equipped and capable of
providing the best health care services for low
risk COVID-19 patients.
Unlike Category 3 and above, they
mandate intense monitoring and treatment in
anticipation of their deterioration, and therefore
sent to Hospital Sungai Buloh. They will be
either be placed in normal wards or intensive
care unit (ICU) if worsens. If a patient recovers
or moved down to Category 1 or 2, the patient
will be sent to PKRCs until full recovery. All
patients will be given colour-coded stickers
based on their categories; green for Category 1,
yellow for Category 2 and red for Category 3
prior to transportations.
According to the Works Ministry of
Malaysia, construction sites in the Klang Valley
may continue to operate as usual, subject to the
standard operating procedures. The COVID-19
swab tests are mandatory or all construction sites
within the Klang Valley and not just in COVID-
19 red zones. The PKDs are responsible to con-
duct contract tracings and screenings at these
areas. These resulted in alarming high numbers
of positive cases than expected.
Figure 1: (Left) Registration, identity confirmatory check by the PKD staff. (Right) As seen is the stand thermometer that was used and
the clerking process by the Inner Ring
MASS TRIAGING AND RETRIEVAL OF COVID-19 PATIENTS
Dr Amira Farhana Abdul Khalil

This diagram above illustrated the Organization
Chart of Command Control. The Base Com-
mander gives instruction and received infor-
mation to and from the Field or Mission Com-
mander, which will further pass on to the Outer
and Inner Ring. The Outer and Inner Ring are
stationed in the red zones with full personal pro-
tective equipments (PPEs). A team consist of an
Emergency Physician, Medical Officers, Staff
Nurses, Assistant Medical Officers and a driver.
The equipments that were brought with the team
are SpO2 probes, thermometers, PPEs, food stuff
for the team and decontamination supplies.
There are a lot of potential problems
that were encountered along the process. We
started with identifying their names and passport/
IC numbers. Some of the patients had similar
common names which can be confused at times.
(Example: Mohamad, Bahadur, Islam, Miah,
Aung). It is important to get their ID right in the
beginning to ensure the process flows smoothly.
Once they are correctly identified, they will get a
sticker with their personal registration number.
The information are entered into a standardised
Google Sheet form which will be monitored by
the Base Commander. Unpredictable factors such
as the weather, the suitability of the site (e.g.
size, humidity) were also the hurdles the team
had to deal with on every mission.
The next stage of the triaging is to
gather vitals signs that were required including
saturation of oxygen, heart rate, respiratory rate
and temperature. At this point, we should be able
to pick up warning signs (if any). Age, co-
morbids and symptomology were also apart of
the screening process. A positive COVID-19
patients tend to desaturate even on minimal exer-
tion, therefore patients were asked to do a Sit-to-
Stand Test for one minute to assess exercise-
induced oxygen desaturation6,7
. This test is vali-
dated, it is proven safe, it is used globally and
can be conducted anywhere. They are likely to
be specific but not sensitive8
.
The use of ultrasound as a diagnostic
adjunct is indicated when there are presence of
symptoms or warning signs in a patient. The
warning signs are fever of 38 degrees Celcius or
more, heart rate of 120 bpm or more, respiratory
rate of 20 times/min or more and/or SPO2 95%
or less. If in the event that a patient with warning
signs have any ultrasound findings which is
suggestive of pneumonia, the patient will
automatically be labeled as Category 3.
After triaging process is completed,
next would the process of transporting the pa-
tients to respective areas based on their catego-
ries. Arranging these patients prior to transport is
extremely crucial to prevent patients from run-
ning away or transported to the wrong destina-
tion. As an example, patients in Category 1 and 2
are physically arranged based on their registra-
tion numbers in proper order. Identifications and
vitals signs are checked repeatedly for quality
control. If a vital sign does reflect Category 3 or
more, the vital signs and examinations are re-
peated to avoid error or mistriaging.
Among the places that our team had
the opportunity to partake were the Malaysia
Agro Exposition Park Serdang (MAEPS), immi-
gration detention centres (DTI), Top Glove Cor-
poration in Klang, Tamu Hotel, Seri Pacific
Hotel, Ancasa Hotel, Kuala Lumpur Internation-
al Hotel and the most recent, Sky Meridien con-
struction site. We were very happy to see Tan Sri
DG himself and our beloved Hospital Director,
Datuk Dr Heric Corray at ground level oversee-
ing the whole triaging process at the latter. Some
of the mission numbers ranged from 20 - 1200
patients per day depending on the site.
From our various experiences, we had
found that the patients who came for the screen-
ing do not even know that they were positive for
COVID-19. This saddened us because the pa-
tients ought to be given proper briefing of the
diagnosis, treatment course and breaking the bad
news to them. This can perhaps be improved by
being upfront and honest to them from the get go
therefore creating awareness amongst them.
We have dedicated transportation
team that will arrange the admissions to respec-
tive destinations. There were a few learning
curves along the way which resulted them to
work efficiently with each encounter. They have
excellent communication skills with the Base
Commander and transport hospitals. The
transport vehicles will be escorted by police
officers.
In conclusion, Teamwork is very im-
portant between the hospitals, PKDs and the sites
managements especially in terms of logistic issue
and crowd control. Jabatan Bomba and PDRM
occasionally do step in to aid as well. This initia-
tive will continuously will help in early detection
and treatment of patients, curb the spread of
COVID-19, aid in efficient use of available man-
power and resources efficiently and give team
members learning opportunities. This will also
will go down in history as one of the ways Ma-
laysia fought the ‘war’ of COVID-19.

PAGE 2 3
Figure 2: (Left) Improvisation of the equipment available, stretcher used as table on site. (Right) Selected construction site
used as screening place
Figure 3: Screening and triaging area at Top Glove, Klang.
Figure 4: Patients were arranged according to their category before they were loaded into the bus
Figure 5: (Left) Heavy rain and strong wind did not stop the team from continuing the screening process
(Right) The use of color-coded stickers to categorise the patients
Figure 5: (Left) Team members all prepped and ready to start screening process
(Right) Site visit by Director-General Health Malaysia, Tan Sri Dr Noor Hisham Abdullah .

The World Health Organization
(WHO) declared the outbreak of COVID-19
as a global pandemic in March 2020.
There are more than 213 countries affect-
ed including Malaysia. In Malaysia, 49730
of confirmed cases of COVID-19 has been
reported, with 318 deaths (0.6%) 1. Emer-
gency and Trauma Department of Hospital
Kuala Lumpur (ETD HKL) has been desig-
nated as one of the screening and treat-
ment centers for all suspected and con-
firmed COVID-19 cases by the Ministry of
Health Malaysia (MOH).
As the death toll continues to rise
due to this deadly severe acute respiratory
syndrome coronavirus 2 (SARS-CoV-2)
infection, healthcare workers (HCW) need
to be well prepared and better equipped.
Learning from other countries' experiences,
MOH sorted to purchase more ventilators
and other medical equipment as one of its
preparedness measures. This emerging
disease outbreak forced countries world-
wide to restrict movement by closing their
borders causing massive delays in medical
supply deliveries. Export of these goods
also briefly came to a halt due to major
medical and pharmaceutical conglomer-
ates focusing on coping with internal de-
mands. As the saying goes, necessity is
the mother of inventions, and during these
times of scarcity, physicians sorted to in-
vent different prototypes of Non-invasive
Positive Pressure Ventilation (NIPPV) de-
vices to battle the shortage. The idea of
using snorkelling masks as Non-invasive
Ventilation (NIV) interface originated from
an Italian physician, Dr. Renato Favero.
Together with the engineers at Isinnova,
they designed a new component called the
‘Charlotte valve’; an adapter that connects
the mask to the gaseous source4.
We studied the safety and ap-
plicability of this novel modified snorkelling
mask that has become available in our
center as an NIV interface. The experiment
was done in a darkened room. The pho-
to luminescent powder was used to
represent contaminated secretions and to
allow better visibility upon detecting leak-
age on the mask. This non-toxic powder is
a light-emitting material that is activated
by exposure to ultraviolet (UV) light.The
particle size is between 15-25um 2. UV
light lamps were used to charge the pow-
der resulting in a glow-in-the-dark material
that can assist in locating surface contami-
nation. Monnal T60® ventilator was used
and leakage from the circuit and mask seal
to the face was studied. The volunteer held
the powder inside the mouth and simulated
coughing aftercompleting the leak test. The
experiment was recorded using the video
features on iPhone11 Pro Max (240fps).
Debating data have been pub-
lished in regards to the benefits vs deleteri-
ous effects of NIPPV in COVID-19 patients
11,12,13,14. In practice, NIV is not used
for SARI / COVID -19patients at our center
to abate the risk of delayed intubation and
exposure of HCWs to aerosol droplets.
Also, studies have shown a high rate of
NIV failure in severe hypoxaemic patients.
However, during this time of crisis and
scarce resources, physicians may consid-
er alternatives to intubation and the need
for ventilatory support.
ROLE OF MODIFIED SNORKELLING MASK NIPPV DEVICE IN
COVID-19 AND SARI PATIENTS.
Nurul Liana Binti Roslan, Shamala Nair Sugu Kumaran, Mahathar Abd. Wahab
Figure 1:
The modi-
fied snor-
keling
mask
NIPPV de-
vice’s com-
ponents.

PAGE 25
Figure 2: The assembly of the modified snorkelling mask NIPPV device. The 3D-printed adapter needs to be attached
to the mask. We used medical tape to reinforce the loose connection and to prevent it from dislodging.
The goals of NIV are to maintain sufficient alveolar
ventilation, improve gas exchange, and decrease work of
breathing. However, successful outcomes depend on many
factors including the proper interface fitting. According to
Luján et. al. (2018), tidal volume in a spontaneously breath-
ing patient varied according to the device and mask fitting.
Even with the perfect fit, the magnitude of leakage is di-
verse 2,8. The difference between inspired and expired
volume corresponds to the leakage. The acceptable per-
centage of leakage is less than 20%. This value is derived
from the compressible volume (the amount of gas com-
pressed in the circuit for every pressure generated by the
ventilator during the inspiratory phase) 2. During our study,
no leakage detected during the leak test whilst using the
ventilator at the PEEP of 0 cmH20. This suggests that the
mask size is appropriate and well-fitted for the volunteer.
We further increased the PEEP up to 5 cmH2O for 5
minutes in which a significant volume of leakage was
observed. A close inspection performed under UV light
detected a minimal amount of powder leaked on both sides
of the mask. The photo luminescent powder was found be-
yond the inner borders of the mask. Therefore, the safety of
applying this device on SARI or COvID-19 patients needs to
be further evaluated especially if used in a positive pressur-
ized room. We need to highlight that we did not measure
tidal volume (TV) nor quantify the volume of leakage in this
study.
Cleaning and disinfecting modified snorkelling mask
is challenging due to the design of the silicon seal. We
were still able to detect the powder under UV light after
washing it thoroughly twice with distilled water and soap. As
the mask is commercially available and considered safe for
non-infective persons, we support the idea of HCWs using
the mask as PPEs instead of as ventilatory devices for sick
patients 9. We proposed HCWs to have personalised
masks due to hygiene purposes and different sizing which
requires an individualised mask-seal.
COVID-19 or SARI patients should be using NIV in
an isolated negative pressure room if there is no ventilator
available. In the event of inadequate PPE, HCWs may con-
sider using this modified device while performing aerosol-
generating procedures. A larger-scale study is needed to
evaluate the outcome of patients using this innovative inter-
vention. The cost-effectiveness and safety profile of modi-
fied snorkelling masks in delivering NIV however needs to
be further enhanced and refined.
Link to the video:https://drive.google.com/file/
d/1n02tnsSps08qDHbr6h1CzJ2m7aoDrMK7/view?
usp=drivesdk
Disclaimer: This experiment was done as an initiative of
physicians in battling COViD-19. No financial incentives
were received by the authors. No harm occurred during this
experiment.

COVID-19 JOURNEY
DEPLOYMENT OF CRC STAFF FOR COVID WARD ROTATION IN HKL.
 Dr Karina Koh
 Dr Lee Jen Ven
 Dr Noor Hidayu Wahab
 Dr Raj Kumar A/L Sevalingam
 KJ Azura Ramli
DEPLOYMENT OF CRC STAFF FOR COVID-19 CARE ROTATION OUTSIDE HKL.
 Dr Nor Aliya Ayub : Pusat Kuarantin dan Rawatan COVID-19 (PKRC), MAEPS, Serdang.
 Dr Nadiah Ismail : COVID-19 Quarantine Centre
 Dr Nik Nur Eliza Mohamed : COVID-19 Quarantine Centre
 Dr Raj Kumar A/L Sevalingam: Semporna, Sabah.

DEPLOYMENT/ATTACHMENT OF STAFF TO BILIK GERAKAN/CPRC
 Dr.Nurdiana Hussin (Bilik Gerakan HKL)
 Dr.Nadiah ismail (Bilik Gerakan OSH)
 Dr Noorhidayu Wahab (PKD Titiwangsa)
 Dr Siti Zubaidah Othman(PKD Titiwangsa)
 Dr Nor Aliya Ayub (PKD Cheras)
 Dr Nur Aisyah Abdul Rahim (PKD Titiwangsa)
 Dr Mohd Azizuddin Amir Shariffuddin (COVID-19 Mental Health & Psychological Counseling
Support for Healthcare Workers )
COVID-19 JOURNEY

RESEARCH ACTIVITIES
 Assessment of Serological Response and Potential Risk Factors for COVID-19 Infection
Among Healthcare Workers- Dr Nor Aliya Ayub, Dr Raj Kumar, KJ Azura Ramli,
PPP Muhammad Al-Hafiz
PAGE 28
COVID-19 JOURNEY
 Faceshield production by CRC staff during early outbreak

RESEARCH ACTIVITIES
 A Descriptive Study on the Clinical Characteristics of COVID-19 Infections in Malaysia
- Dr Siti Zubaidah Othman, Dr Noorhidayu Wahab, Dr Nik Nur Eliza, Dr Nadiah Ismail
 The effects of vitamin C supplementation in the treatment for COVID-19: A multi-centre
prospective observational study
- Dr Nadiah Ismail.
 WHO Solidarity Trial
- Dr Karina Koh, Dr Lee Jen Ven, Dr Nadiah Ismail
 Case Series SARI/COVID-19 in HKL
- Dr Duratul’ain Mohamad Nazri, Dr Nur Aisyah Abdul Rahim, KJ Azura Ramli.
PAGE 29
COVID-19 JOURNEY

RESEARCH POSTER

PAGE 32
PUBLICATION BY HKL STAFF 2020
[JANUARY]
Author Research Title Journal
Impact
Factor
Department
Kin Fon Leong Trachyonychia The Journal of Paediatric 2.77 Paediatric
M. Mardhiah, Nor Azimah Abdul
Azize, Yusnita Yakob, Ngu Lock Hock
Clinical, Biochemical and Mutational Findings
in Biotinidase Deficiency Among Malaysian
Population
Molecular Genetics and
Metabolism Reports
0.51 Genetic
Tengku Nazim Tengku Yusof
Treatment Options for Turf Toe: A Systematic
Review
The Journal of Foot and
Ankle Surgery
0.62 Orthopaedic
Zainal Hazleen, Adawiyah Jamil,
Norazirah Md Nor, Tang Min Moon
Skin pH Mapping and Its Relationship with
Transepidermal Water Loss, Hydration and
Disease Severity in Adult Patients with Atopic
Dermatitis
Skin Research Technology 0.16 Dermatology
Tang Min Moon
Minimal Agreement Between Basophil
Activation Test and Immunoassay in
Diagnosis of Penicillin Allergy
Allergologia et
Immunopathologia
1.276 Dermatology
Bernard Yu-Hor Thong, Michaela
Lucas, Tang Min Moon
Drug Hypersensitivity Reactions in Asia:
Regional Issues and Challenges
Asia Pacific Allergy 1.826 Dermatology
Chin Chin Ch’ng, Loke Meng Ong,
Kelvin Khai Meng Beh, Wan Shaariah
Md Yusuf, Thian Fook
Chew, Ming Lee Lee, Lai Seong Hooi,
Hin Seng Wong, Shahnaz Shah Fir-
daus Khan, Ghazali Ahmad
Survival Advantage of Initiating Dialysis in
Elderly and Non-Elderly Incident End Stage
Kidney Disease Patients
Asian Pacific Society of
Nephrology
0.59 Nephrology
Kin Fon Leong Tinea Capitis: An Updated Review
Recent Patents on
Inflammation & Allergy
Drug Discovery
0.44 Paediatric
Nguk Chai Diong, Benedict
Dharmaraj, Cindy Thomas Joseph,
Narasimman Sathiamurthy
Growing Teratoma Syndrome of Mediastinal
Nonseminomatous Germ Cell Tumor
Annals of Thoracic
Medicine
0.5
Surgery
Anaesthesiology
Maninderpal Kaur Gill
Evaluation of Contrast-Enhanced Digital
Mammography (CEDM) in The Preoperative
Staging of Breast Cancer: Large-Scale
Single-Center Experience
The Breast Journal 0.66 Radiology
Dhayalen Krishnan, Siti SM Zaini,
Kartikasalwah A Latif, Joyce Pauline
Joseph
Neurosyphilis Presenting as Acute ischemic
Stroke
Clinical Medicine 0.46
Radiology
Medical
Neurology
Sie Chong Doris Lau, Mohamed Najib
Mohamed Unni, Kok Hoi The, Mimi
Azura Aziz, Zulaiha Muda, Shoba
Anne Thomas, Shiao Wei Quah,
Hishamshah Ibrahim, Ida Shahnaz
Othman
Autologous Stem Cell Transplantation
Following High-Dose Chemotherapy in
Children with High-Risk Neuroblastoma:
Practicality in Resource-Limited Countries
Paediatric Blood & Cancer 1.14
Paediatric
Pathology
Yew Keong Ng, Noraida Mohamed
Shah, Ly Sia Loong, Lay Ting Pee,
Wei Wen Chong
Patient-Centred Care in the Context of
Pharmacy Consultations: A Qualitative Study
with Patients and Pharmacists in Malaysia
Journal of Evaluation in
Clinical Practice
0.59 Pharmacy
Yek-Ching Kong, Li-Ping Wong,
Chiu-Wan Ng, Nur Aishah Taib,
Nanthini Thevi Bhoo-Pathy,
Mastura Mohd Yusof, Azlina Firzah
Aziz, Prathepamalar Yehgambaram,
Wan Zamaniah Wan ishak,
Cheng-Har Yip, Nirmala Bhoo-Pathy
Understanding The Financial Needs Following
Diagnosis of Breast Cancer in A Setting with
Universal Health Coverage
The Oncologist 2.61
Oncology and
Radiotherapy
Syahril Rizal Arsad, Sei Haw Sem,
Jeremy Prakash Silvanathan,
Rashdeen Fazwi, Muhammad
Nawawi
Hemi-Hamate Arthroplasty in Chronic
Fracture-Dislocation of Proximal
Interphalangeal Joint of Fingers:
A Report of Two Cases
Cureus - Orthopaedic

[JANUARY]
Impact
Factor
Department
Fu Liong Hiew
Grave Prognosis of The Musclespecific Kinase
(Musk)-Positive Myasthenia Gravis (MG):
A False Prejudice
Annals of Indian Academy
of Neurology
0.33 Neurology
Kin Fon Leong
Lichen Striatus with Nail involvement in A
6-Year-Old Boy
Case Reports in
Paediatrics
- Paediatric
Karen Michell Othaya Kumar,
Rabiatul Basria S.M.N. Mydin
Nasopharyngeal Cancer : Geographic
Variation and Risk Factors
Malaysian Journal of
Medicine and Health
Sciences
0.12 Genetic
Mansharan Kaur Chainchel Singh
Saiful Nizam Abdul Rashidd, Suzana
Abdul Hamide, Mohd Shah
Mahmood, Siew Sheue Feng,
Hapizah Mohd Nawawi, Effat Omar
Correlation and Assessment of Coronary
Artery Luminal Stenosis: Post-Mortem
Computed Tomography Angiogram versus
Histopathology
Forensic Science
International
0.87 Forensic
Shukriyah Sulong, Azmi Alias,
Fadzlishah Johanabas, Johari Yap
Abdullah, Badrisyah Idris
Intracranial Volume Post Cranial Expansion
Surgery Using Three-Dimensional Computed
Tomography Scan Imaging in Children with
Craniosynostosis
The Journal of craniofacial
surgery
0.44 Neurosurgery
Ong Swee Gaik, Ding Hui Jen
Vitamin D Status in a Monocentric Cohort of
Systemic Lupus Erythematosus (SLE) Patients
and Correlations with Clinical and
Immunological Profile
Medical Journal of
Malaysia
0.23 Medical
Rahayu Draman, Rabeya Yousuf,
Suria Abdul Aziz, Chuan Hun Ding,
Suzana Zainol, Chooi Fun Leong
A Preliminary Study on Coagulation
Parameters and Sterility of Thawed Refrozen
Fresh Frozen Plasma
Indian Journal of
Haematology & Blood
Transfusion
0.21 Pathology
Nur Dini Jalaludin
Cavernous Haemangioma: A Rare Cause of
Hoarseness in Adults
International Journal of
Human and Health
Sciences
- Pathology

PAGE 34
[FEBRUARY]
Impact
Factor
Department
Chee Sing Wong
Standardised Neonatal Parenteral Nutrition
Formulations - Australasian Neonatal Parenteral
Nutrition Consensus Update 2017
BMC Pediatrics 0.85 Paediatric
Hamidah Alias, Sasirekha Krisnan
Morthy, Syed Zulkifli Syed Zakaria,
Zulaiha Muda, Azmi Mohd Tamil
Behavioral Outcome Among Survivors of
Childhood Brain Tumor: A Case Control Study
BMC Pediatrics 0.85 Paediatric
Kai Wei Lee, Siew Mooi Ching, Fan Kee
Hoo, Noraihan Mohd Nordin,
Navin Kumar Devaraj, Ai Theng Cheong,
Yook Chin Chia
Neonatal Outcomes and its Association Among
Gestational Diabetes Mellitus with and without
Depression, Anxiety and Stress Symptoms in
Malaysia: A Cross-Sectional Study
Midwifery 0.84
Obstetric and
Gynaecology
Choong Yi Fong, Fen Ni Ong, Lai Choo
Ong, Teik Beng Khoo, Ming Lee Lee
Vitamin D Deficiency and Insufficiency in
Malaysian Children with Spina Bifida
Nature, Spinal cord 0.72 Paediatric
Chee Kok Yoon
Network Analysis of the Depressive
Symptom Profiles in Asian Patients with
Depressive Disorders: Findings from The Research
on Asian Psychotropic Prescription Patterns for
Antidepressants (REAP-AD)
Psychiatry and Clinical
Neurosciences
1.14 Psychiatry
Nicholas Tze Ping Pang, Ruziana
Masiran, Kit‐Aun Tan, Aminah Kassim
Psychological Mindedness as a Mediator in the
Relationship Between Dysfunctional Coping Styles
and Depressive Symptoms in Caregivers of
Children with Autism Spectrum Disorder
Perspectives in Psychiatric
Care
0.44 Psychiatry
Chiao Yee Lim
Retrospective Cohort Study of 68 Sacral Giant Cell
Tumours Treated with Nerve-Sparing Surgery and
Evaluation on Therapeutic Benefits of Denosumab
Therapy
The Bone & Joint Journal 2.38 Orthopedic
Keng Seng Fu, Pei Yin Wong, Fu Liong
Hiew
Therapeutic Plasma Exchange (TPE) for
Semi-Critical Neurology Presentations in a
Non-Acute Neurology Set-Up: Clinical Practice and
Challenges
BMJ 3.27 Neurology
Faraizah Abdul Karim
Simplifying Surgery in Haemophilia B: Low Factor
IX Consumption and Infrequent Infusions in
Surgical Procedures with Rix-F
Thrombosis Research 1.04
Pusat Darah
Negara
Fu Liong Hiew
Grave Prognosis of the Musclespecific Kinase
(Musk)-Positive Myasthenia Gravis (MG): A False
Prejudice
Annals of Indian Academy of
Neurology
0.33 Neurology
Norazirah Md Nor, Sabeera Begum
Kader Ibrahim, Bee Koon Poh
Food Restriction, Nutrition Status and Growth in
Toddlers with Atopic Dermatitis
Pediatric Dermatology 0.51 Paediatric
Sze-Voon Yee, Abdul Rahman Ghani,
Azman Raffiq
Review of CHESS Score in SAH Patients in Local
Malaysian Population
Journal of Neurosciences in
Rural Practice
0.3 Neurosurgery
Daniel Teck Lung Wong, Seng Fah
Tong, Tuti Iryani Mohd Daud,
Salina Abdul Aziz, Marhani Midin
Factors Influencing Professional Help-Seeking
Behavior during First Episode Psychosis in Schizo-
phrenia: An Exploratory Study on Caregivers’
Perspective
Frontiers in Psychiatry 1.23 Psychiatry
Azlina Ibrahim, Alvin Oliver Payus
“A Double-Edged Sword”: A Case Report on Liver
Injury Side-Effect of Anti-Tuberculosis Drug on
Liver Tuberculosis Patient
Borneo Journal of Medical
Sciences
- Medical
Kaitian Koo, Rushitaa Nagayah,
Sabeera Begum
The Use of Complementary and Alternative
Medicine in Children with Atopic Eczema at a Ter-
tiary Care Centre in Malaysia
Complementary Therapies in
Medicine
0.58
Paediatric
Pharmacy
Priscilla Dasa, Nyi Nyi Naing, Nadiah
Wan-Arfah, KON Noorjand, Yee Cheng
Kuehe, Kantha Rasalingam
Depression, Anxiety and Coping Styles in Patients
with Brain Pathology in a Malaysian Hospital
Conference Proceedings,
3rd USM-International
Conference On Social
Sciences 2019
- Neurology
Lim Chiao Yee
Retrospective Cohort Study of 68 Sacral Giant Cell
Tumours Treated with Nerve-Sparing Surgery and
Evaluation on Therapeutic Benefits of Denosumab
Therapy
The Bone and Joint Journal 4.306 Orthopedic

[MARCH]
Impact
Factor
Department
Siti Fatimah Badlishah-Sham, Anis
Safura Ramli, Mohamad Rodi isa,
Nurzakiah Mohd Zaki
Are Malaysian Type 2 Diabetes Patients
Willing to be Trained to Speak to Their Off-
Spring About Risk of Diabetes and Preventive
Measures?
BMC Family Practice 1.06 Medical
Azura Mohd Affandi, Ch’ng Chin
Chwen, Heah Sheau Szu, Leow
Wooi Leong, Noor Zalmy Azizan,
Sabeera Begum, Zaridah Zainuri,
Siti Mariam Tukimin
Management of Atopic Eczema in Primary
Care
Malaysian Family
Physician
0.17
Dermatology
Paediatric
Pharmacy
Kaitian Koo, Rushitaa Nagayah,
Sabeera Begum, Tuan Mazlelaa
Tuan Mahmood, Noraida Mohamed
Shah
The Use of Complementary and Alternative
Medicine in Children with Atopic Eczema at a
Tertiary Care Centre in Malaysia
Complementary Therapies
in Medicine
0.58
Paediatric,
Pharmacy
Suganthy Robinson
Analysis of Internet Searches Using Google
Trends to Measure Interest in Sun Protection
and Skin Cancer in Selected South-East Asian
Populations
Photodermatol
Photoimmunol
Photomed
2.387 Dermatology
Anizar Faizi Anoar
Clinical and Radiological Results of The
Vascularized Medial Femoral Condyle Graft
for Scaphoid Non-Union
Archives of Orthopaedic
and Trauma Surgery
1.15 Orthopedic
Mohd Raffiz Mohd Ali
The State of Neurosurgical Training and
Education in East Asia: Analysis and Strategy
Development for This Frontier of The World
Neurosurgical Focus 1.29 Neurosurgery
Nor Salhana Mohammed Wazir,
Tee Chun Keat
Psychosis During Multidrug Resistant
Tuberculosis Treatment: A Case Report
Psychiatry
- Psychiatry
Ros Suzanna Ahmad Bustamam,
Yu Kong Leong, Flora Li Tze Chong,
Florence Wong Yoke Fui, Yew-Teik
Cheong, Goh Kenny
A Retrospective, Observational Study to
Determine The Patient and Tumor
Characteristics of HER2-Positive Breast
Cancer Patients Treated at Five Main Public
Cancer Centers in Malaysia
Asian Journal Oncology -
Oncology and
Radiotherapy
Siew Wah Lee
Lung-Protective Mechanical Ventilation
Strategies in Paediatric Acute Respiratory
Distress Syndrome
Pediatric Critical Care
Medicine
1.21 Paediatric
Charlotte Kvist Lautrup,
Keng Wee Teik
Delineation of Musculocontractural
Ehlers-Danlos Syndrome Caused by
Dermatan Sulfate Epimerase Deficiency
Molecular Genetic
Genomic Medicine
0.9 Genetic
Kavitha Rethanavelu,
Jasmine L. F. Fung
A Case of G1013R FBN1 Mutation:
A Potential Genotype–Phenotype Correlation
in Severe Marfan syndrome
American Journal of
Medical Genetics
- Genetic

PAGE 36
[APRIL]
Impact
Factor
Department
Yi Hui Foo, Tunku Sara Tunku Ahmad
Yahaya, Tze Yang Chung, and Jeremy
Prakash Silvanathan
Photobiomodulation After Neurotization
(Oberlin Procedure) in Brachial Plexus Injury:
A Randomized Control Trial
Photobiomodulation,
Photomedicine and Laser
Surgery
- Orthopedic
Azad Hassan Abdul Razack, Noor
Ashani Md Yusoff
United in Fight Against Prostate Cancer (UFO)
Registry: First Results from A Large,
Multi-Centre, Prospective, Longitudinal
Cohort Study of Advanced Prostate Cancer
in Asia
BJU International 2.01 Urology
Harikrishna K. R. Nair, Sylvia SY
Chong, Abdul Manan Othman
Validation of Harikrishna Periwound Skin
Classification for Wound Assessment
Journal of Wound Care 0.59 Medical
Ganapathi P, Nurul Yaqeen ME,
Zamzurina AB
It is Not Asthma! An Arcane Case of 'Scimitar'
Syndrome: A Case Report
Medical Journal of
Malaysia
0.23 Medical
Alexander K C Leung, Kin Fon
Leong, Joseph M Lam
An Ulcerated Giant Segmental Hemangioma
Resulting in Contracture of The Left Elbow
Paediatric & Child Health 0.54 Paediatric
Factor VIII Activity and Bleeding Risk During
Prophylaxis for Severe Hemophilia A:
A Population Pharmacokinetic Model
Haematologica 2.93
Pusat Darah
Negara
Kay Ly Chng, Poh Soon Lai,
Sheue Feng Siew, Siti Wira Md Yaro,
Mohd Shah Mahmood
Methanol Related Death in National Institute
of Forensic Medicine, Hospital Kuala Lumpur:
A Case Series
Pathology
0.23 Forensic
Fadzwani B., Raha A.R., Nadia M.N.,
Wan Rahiza WM., Razman J., and
Nordiah A.J
Surgical Antibiotic Prophylaxis: Incidence and
Risk of Surgical Site Infection”
IIUM Medical Journal
Malaysia
0.14 Anaesthesiology
Judith Ju-Ming Wong, Herng Lee Tan,
Siew Wah Lee, Kenneth Tou En
Chang, Yee Hui Mok, Jan Hau Lee
Characteristics and Trajectory of Patients
with Pediatric Acute Respiratory Distress
Syndrome
Pediatric Pulmonology 0.93 Paediatric
Subasri Armon
High Expression of LC3A, LC3B and
P62/SQSTM1 Autophagic Proteins in Human
Colonic Ganglion Cells
Pathology
0.23 Pathology
Muhammad Aminuddin Ashari, isa
Azzaki Zainal, Faizah Mohd Zaki
Strategies for Radiology Departments in
Handling The COVID-19 Pandemic
Diagnostic and
Interventional Radiology
0.65 Radiology
Afshan Sumera, Nur Diana Anuar,
Ammu Kutty Radhakrishnan,
Hishamshah Ibrahim, Nurul H Rutt,
Nur Hafiza ismail, Ti-Myen Tan,
Abdul Aziz Baba
A Novel Method to Identify Autoantibodies
Against Putative Target Proteins in Serum
from Beta-Thalassemia Major: A Pilot Study
Biomedicines 1.51 Paediatric
Karmila Abu Bakar, Khairunnisa
Khalil, Yam Ngo Lim, Yok Chin Yap,
Mirunalini Appadurai, Sangeet
Sidhu, Chee Sing Lai, Azriyanti Anuar
Zaini,Nurshadia Samingan,
Muhammad Yazid Jalaludin
Adrenal Insufficiency in Children with
Nephrotic Syndrome on Corticosteroid
Treatment
Frontiers in Pediatrics
0.87 Paediatric
Ngu Lock Hock
De Novo Variants in CUL3 are Associated
with Global Developmental Delays with or
Without Infantile Spasms
Journal of Human
Genetics
1.39 Genetic
Lai Teck Gew
Late Complications Caused by the Neglected
Biliary Stent
Endoscopy 1.48 Medical
Asrul Akmal Shafie, Azuwana Supian,
Mohamed Azmi Ahmad Hassali,
LockHock Ngu,Meow-Keong Thong,
Hatijah Ayob,
Rare Disease in Malaysia: Challenges and
Solutions
Public Library of Science
One
1.02 Genetic
Ahmad Rithauddin Mohamed
De Novo Truncating Variants in The Last
Exon of SEMA6B Cause Progressive
Myoclonic Epilepsy
American Journal of
Human Genetics
7.38 Paediatric

[MAY]
Impact
Factor
Department
Yin Ye Lai, Intan Nureslyna
Samsudin, Normaizuwana
Mohamed Mokhtar,
Subashini C. Thambiah
Persistent Hyponatremia in an Elderly
Patient
Clinical Chemistry 1.92 Pathology
Jamuna Rani Appalasamy, Joyce
Pauline Joseph, Siva Seeta Ramaiah,
Anuar Zaini Md Zain, Kia Fatt Quek,
Kyi Kyi Tha
Video Narratives intervention Among Stroke
Survivors: Feasibility and Acceptability Study
of A Randomized Controlled Trial
Journal of Medical
Internet Research Aging
- Neurology
Raevathi Omasanggar, Choo Yee Yu,
Geik Yong Ang, Nor Aina Emran,
Normayah Kitan, Anita Baghawi
Mitochondrial DNA Mutations in Malaysian
Female Breast Cancer Patients
one
1.02 Surgery
Normayah Kitan,
one
1.02 Surgery
Chee Chung Liu, Adzleen Mohmood,
Norhafizah Hamzah, Jia Him Lau,
Nurliza Khaliddin, Jamalia Rahmat
Intra-Arterial Chemotherapy for
Retinoblastoma: Our First Three-and-A-Half
Years' Experience in Malaysia
one
1.02 Ophthalmology
Siti Norbaya Masri, Wan Nazirah
Wan Abu Bakar, Salbiah Hj Nawi
Species Distribution and Clinical Profiles of
Coagulase-Negative Staphylococci (Cons)
Isolated from Blood Cultures Among
Paediatric Patients in Hospital Kuala Lumpur
The Medical Journal of
Malaysia
0.23 Pathology
Ann Nie Kong, Choong Yi Fong, Ching
Ching Ng, Ahmad Rithauddin
Mohamed
Association of Common Genetic Variants
with Vitamin D Status in Malaysian Children
with Epilepsy
Seizure 0.85 Paediatric
Boon Yean Chai, Wai Kien Yip,
Noraini Dusa, Norhafizah
Mohtarrudin, Heng Fong Seow
Loss of interleukin-17RA Expression is
Associated with Tumour Progression in
Colorectal Carcinoma
Pathology Oncology
Research
0.69 Pathology
Thahira Jamal Mohamed,
Determining Standardized Causes of Death of
Infants, Children, and Adolescents Living with
HIV in Asia
AIDS Journal
2.45 Paediatric
Anita Baghawi
one
1.02 Surgery
Moonyza Akmal Ahmad Kamil
The Asia Pacific Hidradenitis Suppurativa
(Aphis) Foundation: Promoting Hidradenitis
Suppurativa Research in The Asia Pacific
Dermatology
0.61 Dermatology
Dyoi E Low, Ahmad Fauzi
Nurul-Aain, Wooi Chiang Tan,
Mohammed Faizal Bakhtiar, Shahnaz
Murad, Choong Chor Chang, Chun
Lai Too, Min Moon Tang
HLA-B*58: 01 Association in
Allopurinol-induced Severe Cutaneous
Adverse Reactions: The Implication of
Ethnicity and Clinical Phenotypes in
Multiethnic Malaysia
Pharmacogenetics and
Genomics
0.77 Dermatology
Kai Wei Lee, Siew Mooi Ching, Fan
Kee Hoo, Vasudevan Ramachandran,
Seng Choi Chong, Noraihan Mohd
Nordin, Navin Kumar Devaraj
Factors Associated with Poor-to-Moderate
Quality of Life Among Pregnant Women with
Gestational Diabetes Mellitus:
A Cross-Sectional Study in Malaysia
Quality of life Research 1.12
Obstetric and
Gynaecology
Tengku Nazim Tengku Yusof
Platelet-Rich Plasma Injection for the
Treatment of Hamstring injuries:
A Systematic Review and Meta-Analysis with
Best-Worst Case Analysis
The American Journal of
Sports Medicine
3.24 Orthopedic
Harikrishna Kr Nair Non-Healing Venous Leg Ulcer
Journal of Wound Care
0.59 Medical

PAGE 38
[MAY]
Impact
Factor
Department
Jian Lynn Lee, Noraida Mohamed
Shah, Mohd Makmor-Bakry, Farida
Hanim islahudin, Hamidah Alias,
Lokman Mohd Noh, Shamin Mohd
Saffian
A Systematic Review and Meta-Regression
Analysis on The Impact of Increasing IgG
Through Level on Infection Rates in Primary
Immunodeficiency Patients on Intravenous
IgG Therapy
Journal of Clinical
Immunology
1.58 Paediatric
Efficacy and Safety of Rix-FP in Surgery:
An Update from A Phase 3b Extension Study
Thrombosis Research 1.04
Pusat Darah
Negara
Yue Hui Lau, Hazfadzila Mohd
Unit, Lay Peng Lee, Weng Khean
Loh, Fu Liong Hiew
Temporal Dispersion in Demyelination of
POEMS Syndrome and Castleman Disease
Clinical Neurophysiology
Practice
0.58 Neurology
Asrul Akmal Shafie, Irwinder Kaur
Chhabra, Jacqueline Hui Yi Wong,
Noor Syahireen Mohammed,
Hishamshah Mohd Ibrahim,
Hamidah Alias
Health-Related Quality of Life Among
Children with Transfusion-Dependent
Thalassemia: A Cross-Sectional Study in
Malaysia
Health and Quality of Life
Outcomes
1
Paediatric
Pharmacy
Reana Devi Arunasalem, Ahmad
Zaid Zanial
MIBG Therapy for Large Relapsed
Pheochromocytoma and Inoperable
Paraganglioma: Case Series and Literature
Review
The International Journal
of Medicine and Sciences
-
Nuclear
Medicine
Alexander K C Leung, Benjamin
Barankin, Kin Fon Leong
Henoch-Schönlein Purpura in Children:
An Updated Review Current Pediatric Reviews
0.36 Paediatric
Alexander K C Leung, Joseph M Lam,
Kin Fon Leong, Kam Lun Hon
Infantile Hemangioma: An Updated Review
Current Pediatric Reviews
0.36 Paediatric
Ammar Manas, Mohd Yazid
Bajuri, Rashdeen Fazwi Muhammad
Nawawi
Isolated Tuberculosis of The Wrist:
Subtle But Destructive
Cureus - Orthopedic
Fatimahtulzahrah Saparmin,
Vaishnavi Jeyasingam
Successful Spontaneous Pregnancy After
Pelvic Radiotherapy for a Sacral Giant Cell
Tumor: A Case Report
Precision Radiation
Oncology
-
Radiotherapy
and Oncology
Sivakami Janahiraman, Chan Yen
Tay, Jie Min Lee, Wen Ling Lim,
Chun Hoe Khiew, Irina ishak, Zakry
Yahya Onn, Mohd Razali Ibrahim,
Chun Keat Chew
Effect of an Intensive Patient Educational
Programme on The Quality of Bowel
Preparation for Colonoscopy: A Single-Blind
Randomised Controlled Trial
BMJ
Open Gastroenterology
0.96 Pharmacy
Neshalene Ratnakrishnan, Roslinah
Muji, Wan Haslinah
Case series of Ocular Bartonellosis
of Medicine & Sciences
2.399 Ophthalmology
Moonyza Akmal Ahmad Kamil,
Suganthi Thevarajah
Prevalence of Non-Alcoholic Fatty Liver
Disease (NAFLD) Diagnosed by Controlled
Attenuation Parameter on Transient
Elastography and its Predisposing Factors in
Dermatology
2.067 Dermatology
Neshalene Ratnakrishnan, Roslinah
Muji, Wan Haslinah
Case series of Orbital Cellulitis
of Medicine & Sciences
2.399 Ophthalmology

[JUNE]
Impact
Factor
Department
Woh Yon Mak, Jivanraj R. Nagarajah,
Hannah Abdul Halim, Anitha Ramadas,
Zulsairi Mohd Pauzi, Lay Ting Pee,
Nirmala Jagan
Dipeptidyl Peptidase-4 inhibitors Use in Type II
Diabetic Patients in A Tertiary Hospital
BMJ open gastroenterology 0.96 Pharmacy
R. Malek, M. Sundram, S. Omar, J. R.
Sathiyananthan & P. Kumar
Effectiveness of Decision Aid in Men with Localized
Prostate Cancer: A Multicenter Randomized
Controlled Trial at Tertiary Referral Hospitals in an
Asia Pacific Country
Journal of Cancer Education 0.56 Urology
Lai Poh Soon, Mohamad Helmee
Mohamad Noor, Nurliza Abdullah
Stature Estimation of The Malaysian Population
Based on Sacrum CT Scans
Egyptian Journal of forensic
Science
0.36
Radiology
Forensic
Jama'iah Mohd Sharif, Raja Zarina Raja
Shahardin, Ganasalingam Sockalingam
Pattern of Antibiotic Prophylaxis Practice for Dental
Procedures in Children with
Congenital Heart Disease
Journal of Indian Society of
Pedodontics and Preventive
Dentistry
0.28 Paediatric
Hishamshah Mohd Ibrahim, Zulaiha
Muda, Ida Shahnaz Othman, Mohamed
Najib Mohamed Unni, Kok Hoi
Teh, Asohan Thevarajah
Observational Study on The Current Status of
Thalassaemia in Malaysia: A Report from the
Malaysian Thalassaemia Registry
BMJ Open 1.25 Paediatric
Uday Y H Abdullah, Hishamshah brahim,
Noraesah Binti Mahmud, Mohamad Zaki
Salleh, Lay Kek Teh,
Genotype-Phenotype Correlation of Β-Thalassemia
in Malaysian Population: Toward Effective Genetic
Counseling
Haemoglobin 0.36
Paediatric
Haematology
Oncology
Pathology
Shih-Ku Lin, Sandeep Grover,
Roy Abraham Kallivayalil,
Kok Yoon Chee
Dyskinesia is Most Centrally Situated in an Estimated
Network of Extrapyramidal Syndrome in Asian
Patients with Schizophrenia: Findings from Research
on Asian Psychotropic Prescription Patterns
for Antipsychotics
Nordic journal of psychiatry 0.72 Neurology
Chow Xiao Hong, Jeyasakthy Saniasiaya,
Iskandar Hailani
Rare Manifestation of Pott's Spine
Paediatrics And Family
Medicine Poland
ENT
Abdul Rashida, M.K. Singhb, S.S. Feng,
N. Mohd Yatim, M.Y. Sahak, R. Mahmud
Lethal Morel-Lavallée Lesion: A Forensic
Radiology-Pathology Correlation
Radiology Case Report 0.21 Forensic
Wan Azman Wan Sulaiman, Arman
Zaharil Mat Saad, Normala Basiron, Nik
Amin Sahid
Blue Rubber Bleb Nevus Syndrome in A Malay Girl:
A Case Report and Literature Review
Surgery Case Reports
0.23
Plastic and
Reconstructive
Surgery
Long-Term Safety and Efficacy of N8-GP in Previously
Treated Adults and Adolescents with Hemophilia A:
Final Results from Pathfinder2
Journal of Thrombosis and
Haemostasis
1.93
Pusat Darah
Negara
F. Bakhtiara, M.M. Tang, Z.H.M. Yadzira,
N. Abdullaha
Minimal Agreement Between Basophil Activation
Test and Immunoassay in Diagnosis of Penicillin
Allergy
Allergologia et
Immunopathologia
0.37 Dermatology
Harikrishna K R Nair, Nazni Wasi
Ahmad, Chien Huey Teh, Han Lim
Lee, Sylvia Syin Ying Chong
Maggot Debridement Therapy in Malaysia
Lower Extremity Wounds
0.39 Medical
Lay See Khoo, Ahmad Hafizam
Hasmi , Mohamad Azaini
Ibrahim , Mohd Shah Mahmood
Management of The Dead During COVID-19
Outbreak in Malaysia
Forensic Science, Medicine,
and Pathology
0.55 Forensic
Chow Xiao Hong, Nur Aida Razuan, Azila
Alias, Farah Hani Hassan, Zara Nasseri
Zygomatic Root Abscess: A Rare Entity Not to Be
Forgotten!
Auris Nasus Larynx 0.73 ENT
Ahmad Hafizam Hasmi, Lay See Khoo,
Zhao Peng Koo, Muhammad Uzair
Ahmad Suriani, Ain Nurfarahana
Hamdan, Siti Wira Md Yaro, Salmah
Arshad, Sheue Feng Siew, Mohamad
Azaini Ibrahim, Mohd Shah Mahmood
The Craniotomy Box: An innovative Method of
Containing Hazardous Aerosols Generated During
Skull Saw Use in Autopsy on A COVID-19 Body
Forensic Science, Medicine,
and Pathology
0.55 Forensic
Muhammad Ariff M.Y, Dzulkarnain Amir,
Fazir Mohamad, Mohd Fareez O
Epidural Haematoma in a Child: A Case Report
Science and Research
7.583 Orthopedic
Lai Poh Soon, Mohd Helmee M.N.,
Nurliza Abdullah
Original Article: Pelvic Morphometric Analysis Based
on Sex and Ancestry Among Malaysian Population
Forensic Science
1.619 Forensic
Mohammad Ali Mat Zain,
Normala Basiron
Distribution of Anterolateral Thigh Flap Perforator
Vessels and Its Clinical Applications in Malaysian
Population
Archives of Hand and
Microsurgery
-
Plastic and
Reconstructive
Surgery

7th issue of CRC HKL Newsletter 2020

7th issue of CRC HKL Newsletter 2020

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7th issue of CRC HKL Newsletter 2020