By
Ministry of Health Malaysia (MOH)

And
The Society of Occupational and Environmental Medicine (SOEM) of the Malaysian Medical Association (MMA)

March 2006

CONTRIBUTORS

1. Definition of Pandemic Influenza:

Emergence of a new strain of influenza virus to which much or all of the population is susceptible. This new virus is efficiently transmitted from person to person and causes influenza outbreaks in many countries. An example is the emergence of new strain of bird flu (H5N1) virus that is easily and efficiently transmitted from human to human.

2. Symptoms of influenza:

• Acute onset of high grade fever (>38o C)
• Cough
• Sore throat
• Myalgia (muscle ache)
• Joint pain
• Headache
• Malaise

3. Rationale

There is a global concern that an influenza pandemic may occur because of continuing spread of bird-flu (H5N1) virus to domestic poultry in many countries and the emergence of bird-flu cases in human. Such cases have so far been limited to those in close contact with infected bird or poultry. However in the foreseeable future, such spread may occur between human to human. Then, the health and wellbeing of the community at large and specifically the workforce will be of great concern to government and industry.

The Malaysian government has developed a National Influenza Pandemic Preparedness Plan (NIPPP). A summary of the phases in this plan is attached in Appendix 1. Industries too, will need to develop their own preparedness plans to ensure the protection of their employees and business continuity.

The Ministry of Health (MOH) together with the Society of Occupational and Environmental Medicine (SOEM), a professional organisation, which focuses on occupational health have developed recommendations on influenza pandemic preparedness for industries in Malaysia. These recommendations are meant for health practitioners serving industries in Malaysia. These recommendations will also be shared with industries through the appropriate organizations such as the Malaysian Employers Federation and Federation of Malaysian Manufacturers. The final decision on implementing the recommendations however lies with the employer.

For practical purposes, phases 1 and 2 are categorised as pre-pandemic stage whereas phase 3 to 6 is categorised as pandemic stage. These recommendations do not cover post-pandemic phase.

4. Pre-pandemic Action Stage

This stage encompasses phases 1 and 2 stated in the NIPPP.

The actions to be taken include:

5. Pandemic Action Stage

This stage encompasses phase 3 to 6 of NIPPP. This stage occurs when the Malaysian
Government declares a pandemic in the country.
The actions to be taken include:

Appendix 1

LEVEL OF INFLUENZA PANDEMIC PHASES
- Adapted From WHO And Summary Of Strategic Actions

*Source: NIPPP

Appendix 2

General Advice to the Public on Personal Hygiene

Members of the public are advised to take precautionary measures to prevent respiratory tract infection during pandemic influenza:

• Good personal hygiene should be observed at all times.
• Wash hands frequently with liquid soap, especially after sneezing, coughing or cleaning the nose or before preparing food.
• Build up body immunity by practicing healthy lifestyle e.g. eating healthy food, having adequate rest, exercising regularly and avoiding smoking.
• Cover nose and mouth when sneezing or coughing
• Avoid spitting in public places.
• Avoid visiting crowded places with poor ventilation. If you happen to be in crowded places, like shopping malls or cinemas, wear a surgical mask if somebody near you starts coughing or sneezing
• If there is a family member who develops fever or respiratory symptoms within
• 10 days after returning from an affected country, all other members of the family should wear a surgical mask as a precautionary measure.
• Consult the doctor immediately if you develop fever or any respiratory symptoms

Appendix 3

Guidelines On The Use Of Surgical Face Masks
During Influenza Pandemic

Benefit of surgical mask:

It helps contain droplets from those already infected and may provide some protection for those exposed to anyone with respiratory symptoms.

Type of surgical mask to be used:

3 ply surgical mask.

Indications:

1. All health care workers and hospital personnel who is at high risk of contact with suspect or probable PI patients. Doctors, nurses, other health workers and all other workers working, right from the triage area to the isolation ward would fall into this category.
2. All health personnel transporting suspected patients to designated hospitals including sending them home
3. Parents accompanying their children who are admitted to the ward for PI.
4. All personnel involve in triaging (screening) of patients or travelers at entry points
5. All health care working at entry points and not directly involved in triaging (screening)
6. Individuals exhibiting respiratory symptoms
7. Suspected or probable PI patients transported from triage to isolation ward.

 Guidelines on wearing surgical masks (3 Ply)

1. If you have running nose or flu like symptoms, you are advised to stay at home. If you need to go out, make sure you wear a surgical mask.
2. Avoid crowded places. Wear a surgical mask if you cannot avoid them
3. Wash hands before wearing a surgical mask and after taking one off.
4. When wearing surgical mask, the following should be noted:
1. The facemask should fit snugly over the face
2. The coloured side of the mask should face outside
3. Tie all the strings that keep the mask in place
4. The mask should fully cover the nose, mouth as well as the chin.
5. The metallic wire part of the mask should be fixed securely over the bridge of the nose to prevent leakage
6. The surgical mask should not be used more than a day but if it is wet, damaged or soiled by secretions or body fluid at any time, change the mask immediately.
5. Discard all used masks into a plastic bag, which should then be tied properly before     disposing it into a rubbish bin.

Appendix 4

HEALTH ALERT CARD (NOTICE)
FOR TRAVELLERS COMING FROM OR EXITING
INFLUENZA PANDEMIC AFFECTED COUNTRIES OR AREAS

For Malaysians and Visitors:

World Health Organisation has issued an alert on influenza pandemic. If you have flulike symptoms such as fever, cough and any one of these e.g. muscle ache, headache and sore throat you should see a doctor. If you have high fever and difficulty in breathing, you should immediately go to hospital for necessary treatment and please present this card.

*As of ………………… the influenza pandemic affected areas are as follows: …………………………………………………………

Disease Control Division
Ministry of Health Malaysia
Level 3, Block E10, Parcel E,
Pusat Pentadbiran Kerajaan Putrajaya
62590 Putrajaya, Malaysia

* statement will follow WHO report on current status of influenza pandemic

Appendix 5

List of the designated hospitals.

Appendix 6

Case Definitions

a) Suspected case

• A person presenting with history of an acute onset of high fever (> 38º C )
• AND
  Dry cough,
  AND
  one or more of the following: sore throat, nasal congestion/blockage, myalgia, headache, vomiting (infant), fits (infant)
• Close contact* with a person diagnosed with PI within 10 days of the onset of symptoms or recent history of travel to areas** reporting cases of PI

b) Probable case

• A suspected case with limited laboratory confirmation of Influenza A ….. sub-type


• OR


• A person with an unexplained respiratory illness resulting in death with history of close contact with a person diagnosed with PI within the last 10 days or recent history of travel to areas reporting cases of PI.

* Close contact means having cared for, having lived with, or having had direct
   contact with secretions and body fluids of person with PI
** Countries identified as affected areas to date.

Exclusion criteria

A case should be excluded if an alternative diagnosis can fully explain their illness.

Reclassification of cases

As more epidemiological data be made available during the influenza pandemic, WHO may provide new case definitions for pandemic influenza. Thus the status of a reported case may change over time. A patient should always be managed as clinically appropriate regardless of their case status.

• A case initially classified as suspect or probable, for which an alternative diagnosis can fully explain the illness, should be discarded.
• A suspect case who after investigation, fulfill the probable case definition should be reclassified as “probable”.
• A suspect case who dies, on whom no autopsy is conducted, should remain classified as "suspect". However, if this case is identified as being part of a chain transmission of PI, the case should be reclassified as "probable".
• If an autopsy is conducted and no pathological evidence of PI is found, the case should be "discarded".

Appendix 7

Home Observation And Surveillance Order For
Contacts Of Pandemic Influenza

MINISTRY OF HEALTH
MALAYSIA

Reference No:
District Health Office
__________________________
__________________________
Telephone Number: ________________
To:
Name: _________________________
Identification Card Number: __________________
Address: _____________________________
____________________________________
____________________________________

HOME OBSERVATION AND SURVEILLANCE ORDER FOR CONTACTS OF
PANDEMIC INFUENZA (PI) UNDER SECTION 15 (1) THE PREVENTION AND
CONTROL OF INFECTIOUS DISEASES ACT 1988

The World Health Organization (WHO) has described in its case alert that pandemic influenza (PI) may spread through close contacts. Close contact is defined as having lived with or having had direct contacts with respiratory secretions or body fluids of persons with PI.

2. You have been identified as a close contact of a person who is suspected to have PI and there is a possibility that you have been exposed to PI. Under section 15(1) of the Prevention and Control of Infectious Disease Act 1988, allows the authorised officer to order your isolation in any hospitals.

3. In view of the circumstances, the authorised officer has in his opinion you can be attended to in your home and permit you to be put under surveillance and observation at home mentioned above subject to conditions as in Annex A.

4. During the period of surveillance and observation you are required to observe the conditions stipulated in the list. Under section 24 of the Act, any person who disobeys any lawful order issued by an authorised officer shall be liable on conviction in respect of the first offence, to imprisonment for a term not exceeding two years or to fine or to both, in respect of second or subsequent offence, to imprisonment not exceeding five years or to fine or to both, in respect of a continuing offence, to a further fine not exceeding two hundred ringgit for every day during which such offence continues.

Name of authorised officer: ________________________________________
Designation:_________________________________________________________
Date: ___________________
Time: _____________________

ACKNOWLEDGEMENT OF RECEIPT OF A COPY OF HOME OBSERVATION
AND SURVEILLANCE ORDER BY CONTACTS

Signature: ___________________
Name: _________________
Identification Card Number: ____________________________
Date: __________________
Time: ______________

Annex A

HOME OBSERVATION AND SURVEILLANCE ORDER FOR CONTACTS OF
PANDEMIC INFUENZA (PI) UNDER SECTION 15 (1) THE PREVENTION AND
CONTROL OF INFECTIOUS DISEASES ACT 1988

I. WHAT HAS TO BE DONE DURING THE HOME OBSERVATION AND SURVEILLANCE  
   PERIOD?

A. STAY AT HOME DURING THE SPECIFIED PERIOD

1. Stay at home at all times from ____________ to _____________
2. If you have school going children or have siblings who attend school, kindergarten or child care centers, they are also to stay at home at all times for the same period.
3. Arrange for relatives / friends to purchase groceries, or your daily needs.
4. If you urgently need to go out for matters needing personal attention , you need to consult the District Health Officer at : ________________
5. If you need any assistance in your daily needs, call: ____________
6. Minimise contact with friends as far as possible. If friends and relatives do enter your home, please keep a list of their names, contact numbers and the dare of their visit.
7. If your spouse or any other adults in your home have not been issued the home observation and surveillance order, they are free to leave the house and carry on with their daily routine.

B. CHECK FOR SIGN OF FEVER

1. Check for fever daily and this to be monitored for 10 days beginning on ___________
2. Wear the face mask at all times if you have fever or cough, until arrangement can be made for medical attention.
3. If you are unwell or have fever, please call the District Health Officer at ____________ and arrangement will be made for you to seek medical attention.

C. OBSERVE GOOD PERSONAL HYGIENE

1. Maintain good personal hygiene.
2. Cover your mouth when coughing and sneezing
3. Wash your hands every time you touch your nose, mouth or eyes
4. Maintain good indoor ventilation.
5. Surfaces soiled with sputum, phlegm, nose discharge or vomit can be washed with household bleach i.e. chlorox and the recommended dilution: Adding 1 part of bleach to 50 parts of water.

D. WHAT IS NOT TO BE DONE DURING THE HOME OBSERVATION AND  
    SURVEILLANCE PERIOD?

1. Leaving home for any reason including buying groceries, going for a walk, to the playground or public places.
2. Children and their siblings playing with other children outside or inside the home.

REMINDER

Spot checks will be carried out to ensure the above mentioned instruction strictly adhered and if found to be non-compliant, a legal proceeding shall be taken against you under this Act.

Appendix 8

GUIDELINES FOR HAND HYGIENE AND DISINFECTION

A. How to Wash Hands (using non antimicrobial soap and antimicrobial soap)

Adapted from Health Canada Infection Control Guidelines: Hand Washing, Cleaning, Disinfection and Sterilization in Health Care.

B. Decontaminating Hands with an Alcohol-based Hand Rub

To decontaminate hands that are not visibly soiled* using an alcohol-based hand rub:
• Follow the manufacturer’s recommendations on the volume of product to use;
• Apply product to palm of one hand and rub hands together, covering all surfaces of hands and finger, until hands are dry.

Note: * Hand wash if hands are visibly dirty or contaminated with proteinaceous material or are visibly soiled with blood or other body fluids by washing with either a non-antimicrobial soap and water or an antimicrobial soap and water as outlined above, How to Wash Hands (adapted from Health Canada).

 DISINFECTION PROCEDURES:

Table A. Cleaning Procedures for Common Items

Table B. Directions for Preparing and Using Chlorine-based Disinfectants

* Parts per million
* Imperial gallon (4.5 litres)