Coronavirus Disease (COVID-19) Outbreak among Islamic Missionaries in Terengganu state of Malaysia in 2020

Background: Malaysia experienced an outbreak of COVID-19 after Islamic missionaries returned from religious gathering in Sri Petaling Mosque, Kuala Lumpur. The outbreak extended to the state of Terengganu which also resulted in an outbreak in a private Islamic institution known as BKMQ (an anonymized name) in Kuala Terengganu District. Materials and Methods: A descriptive cross-sectional study was conducted to describe the characteristics of COVID-19 cases and the experience of COVID-19 outbreak containment in BKMQ. Results: There were six individuals diagnosed with COVID-19 in BKMQ. Majority of them were male (83.3%), in the age group of 20 to <40 years old (50.0%) and had fever as their symptom (50.0%). The time of last exposure to diagnosis among majority of cases were 12 days, and majority of cases (66.6%) stayed in hospital between 20 days to less than 40 days. Conclusion: The transmission of virus was postulated to be through household exposure and vehicle sharing. Prompt action, immediate lockdown and inter-agencies collaboration were the key factors in successfully controlling the spread of COVID-19 in the institution and community.


Introduction
Coronavirus Disease (COVID-19) is a newly emerging disease, which is caused by severe acute respiratory syndrome coronavirus (SARS-CoV-2) and spreads rapidly from person to person. The virus is transmitted by asymptomatic infected individuals, as well as symptomatic individuals via oral fluid droplets, mainly airborne via coughing or sneezing 1 . Since the COVID-19 outbreak on 31 December 2019, it has hit more than 200 countries or territories with 51,848,261 cases and 1,280,868 deaths as of 13th November 2020 2 .The World Health Organization (WHO) had declared COVID-19 as a pandemic on 11 March 2020 2 . In Malaysia, the first case of COVID-19 was detected on 25th January 2020 among three tourists who had close contact with an infected person in Singapore. 1 One year later, the disease had spread nationwide and there were more than 408,713 cases reported as of end of April 2021 with more than 1,506 deaths related to COVID-19. Malaysia had identified 1,655 COVID-19 clusters as of 30 th April 2021 which affected all states and federal territories of Malaysia 3 . Malaysia experienced an outbreak of COVID-19 after Islamic missionaries returned from a mass religious gathering known as "International Qudamak and Ulamak Malaysia 2020" which was held from 28 th February 2020 until 2 nd March 2020 in Sri Petaling Mosque, Kuala Lumpur 4 . About 30% of COVID-19 cases in Malaysia during the first wave of COVID-19 pandemic were originated from this gathering which involved about 19,000 local and international attendees. As a result, COVID-19 cases had spread to many generations via 17 sub-clusters or outbreaks when the participants of this mass gathering returned to their place of origin, as Sri Petaling Mosque served as a headquarter for Jamaah Tabligh in Malaysia and coordinates all the related activities 5 . Jamaah Tabligh is a group of movement to revive pure Islamic teaching without any affiliation in political and conflicting jurisprudence sect, aiming to propagate good Islamic practices among all Muslims. Tabligh simply means preacher of Islamic teachings 6 . The Sri Petaling Mosque Cluster was declared on 11 th March 2020 and ended on 8 th July 2020 5 . Movement Control Order (MCO) had been imposed in Malaysia under the Prevention and Control of Infectious Disease Act 1988 and the Police Act 1967 under eight different phases as a mitigation strategy starting from 18 th March until 31 st December 2020. Further continuation of MCO will be dependent on the current COVID-19 situation in Malaysia 5 . One of the states in Malaysia which was affected by the COVID-19 outbreak related to Islamic missionaries is Terengganu State. The first COVID-19 case was detected on 13 th March 2020 in Terengganu State, which was related to the religious mass gathering in Sri Petaling Mosque following voluntary screening. The disease had then spread to the next generation when the infected persons went back to a private Islamic institution known as BKMQ (anonymized name) to continue their Islamic missionaries. BKMQ is situated in the district of Kuala Terengganu with approximately 400 occupants, which consisted of 346 students, 36 teachers and staff, as well as their family members. It stretches over seven acres of land area with a mosque, two classrooms buildings, a four stories staff quarters and ten houses. There are 20 students in average per classroom. Only boys are eligible to pursue their study in BKMQ. There were also non-Malaysian students for example those originated from Thailand, Philippines, China, Indonesia, Singapore, Brunei, Vietnam, Cambodia, Yemen, France, and Morocco. Besides functioning as an Islamic religion learning centre, BKMQ also acts as the centre for Non-Governmental Organization of Islamic missionary movement, which is known as Tabligh Jamaat Markaz (Centre for Tabligh Movement) for Terengganu State. Malaysian Jamaah Tabligh and also those from all over the world will gather and transit in BKMQ for one to two days before they were assigned to go out for dakwah (preaching activities) in local surau (smaller version of Islamic religion gathering or activities centre situated in communities) or mosque for three days, 40 days or four months. BKMQ also served as a weekly assembly point to all the jamaah tabligh from all over Terengganu, which falls on every Thursday 7 . An infectious disease outbreak which happened in an institution like BKMQ posed risk of fast spreading to the occupants of the institution, depending on the practice of infectious control, ratio of occupants to space available, age group and immunity status of occupants, as well as the activities held in the institution. 8 The routine function and the mobility nature of people in BKMQ had also created great challenges to outbreak containment. Apart from that, an outbreak linked to an institution will affect the reputation of an institution. Therefore, infectious disease outbreak management related to an institution requires prompt decision and action; and to halt the spread of the disease in the shortest possible duration to reduce casualties and complications. In view of COVID-19 as a newly emerging disease, sharing of knowledge and successful experience in outbreak management especially in an institution is particularly important to give implications and reference to other stakeholders in future management of similar condition. This paper aimed to describe the characteristics of COVID-19 cases and to outline the experience of COVID-19 outbreak containment in a private Islamic institution in Kuala Terengganu district, Terengganu state of Malaysia.

Materials and Methods
From 1 st March 2020 until 30 th June 2020, a descriptive cross-sectional study was conducted in Kuala Terengganu District Health Office based on retrospective record review for COVID-19 cases notified to Kuala Terengganu District Health Office, Terengganu from the cluster period of 13 th March 2020 until 5 th April 2020. The reference populations and the study samples were all COVID-19 cases in BKMQ who fulfilled study inclusion and exclusion criteria. The inclusion criteria were individuals with laboratory confirmed positive test for COVID-19 9 , and they must be the occupant of BKMQ at the time of diagnosis. Samples with incomplete record of 30% variables will be excluded from the study. Data were collected from Kuala Terengganu District Health Office via e-COVID19 online registry (an online database for COVID-19 under the governance of Ministry of Health Malaysia) 9 . Data were then being recorded in a pre-design study proforma. The retrieved information included socio-demographic features, travel history, signs and symptoms, epidemiological risk assessment, movement history 14 days prior to onset of symptoms, numbers of close contacts, laboratory investigation, control and prevention done by the Kuala Terengganu District Health Office. Specific operational definitions were employed in this study. A confirmed case of COVID-19 is defined as individual with positive results of reverse transcription polymerase chain reaction (RT-PCR) for COVID-19 9 . Meanwhile, an outbreak is defined as two or more cases of similar infectious disease happened in close proximity or had epidemiological link to each other and happened within the same incubation period 9 . Fever is defined as measured fever of ≥38°Celcius 9

Socio-demographic and clinical characteristics of among COVID-19 cases
The COVID-19 outbreak related to BKMQ, a private Islamic institution in Kuala Terengganu district started on 13 th March 2020 and ended on 5 th April 2020. A total of six COVID-19 cases were detected in this outbreak, among 400 tested occupants (positivity rate: 1.5%). Sociodemographically, majority of them were male and in the age group of 20 to <40 years old. Clinically, fever was the most common symptom among cases followed by cough, headache and coryza. The time of last exposure to diagnosis among majority of cases were 12 days, and majority of cases stayed in hospital between 20 days to less than 40 days. Details are shown in Table 1 and Figure 1.

Epidemiological link between COVID-19 cases
Initially four cases (Case 1, 2, 4, 6) had attended the "International Qudamak and Ulamak Malaysia 2020" mass gathering which was held from 28 th February 2020 until 2 nd March 2020 in Sri Petaling Mosque. They stayed together in the mosque and mingled with other participants. On 3 rd March 2020, all of them went back to BKMQ. Case 1  In short, all cases had been detected as positive COVID-19 on their first sample except for Case 6. The illustration of epidemiological link between cases is shown in Figure 2.

Discussion
Five out of the six positive COVID-19 cases detected in BKMQ were male. Our finding is in line with finding from Thailand's COVID-19 outbreak related to the same Islamic mass gathering which found male group was more affected than female group 4 . This may be due to a male predominance in Islamic religious gathering, be it in Sri Petaling Mosque or BKMQ. Observational data from Wuhan, China also reported male group as the more pathologically susceptible group to be infected with COVID-19 10 . Previous study had shown that female group was less susceptible to contract COVID-19 as they have higher macrophage and neutrophil activity and hence, better immune response 11 . As for age group, young adults (20 years old until less than 40 years old) were the predominant group among all COVID-19 cases in this COVID-19 outbreak. Similar findings were observed in Thailand and Beijing where majority of cases ranged between the age of 15 years old to 40 years old 4,12 . These findings may be attributed to the lifestyle of young adults who tend to have many social activities with their peers, which in this case, attending religious mass gathering in group with their peers 13 . The duration of last exposure until the detection of positive COVID-19 or presence of symptoms took 10 days or more among the BKMQ cases. Studies found that COVID-19 incubation period differs widely across the world. It can be as short as three days or up to twelve days 14,15 . For example, in a Chinese study, majority of COVID-19 cases showed that the days from exposure to symptom onset took only three to four days 13 . Meanwhile, the duration between day of exposure to onset of symptoms among Islamic missionaries in Thailand was around five days 4 . Majority of our cases had lengthy hospital stay which was around 20 days to more than 40 days. Similar findings were being reported in a systematic review on COVID-19 length of hospital stay globally that it varied from less than a week to nearly 2 months. This was due to the differences in admission and discharge criteria, as well as different timing and frequencies of cases between countries, and the capacity of which the hospitals could cope with during the pandemic 16,17 .
As for current practice in Malaysia, a few criteria were set as the hospital discharge criteria for symptomatic COVID-19 cases. Firstly, at least 10 days have passed since symptom onset. Secondly, at least 24 hours have passed since resolution of fever without the use of antipyretic medications; and thirdly improving clinically in general. As for asymptomatic COVID-19 patients, they can be discharged from hospital 10 days after the date of their first positive RT-PCR test for SARS-CoV-2 9 . An additional criterion for hospital discharge during the BKMQ outbreak period was at least two RT-PCR sample for COVID-19 was tested negative prior to discharge, as the COVID-19 infectivity period was still under research at that period 16 . Hence, the purpose of hospital stay was to provide supportive treatment to those diagnosed as positive COVID-19 until their RT-PCR results turned negative at that time, as an objective measurement that they are not infective anymore.
As for symptoms, most of our cases had fever followed by cough, headache and coryza. But 33% of our cases were asymptomatic. Studies in other settings also pointed out similar findings with fever and cough were the predominant symptoms of COVID-19 4,12 21 .
Besides spatial transmission of virus within transport vehicles, our report also highlighted the transmission of COVID-19 through household exposure. The most likely scenario is that the infected Case 6 had transmitted the virus to his wife (Case 3) and son (Case 5) after they spent substantial amount of time together within the same house, although Case 6 was asymptomatic and being the last one to be detected positive. A systematic review and meta-analysis reported that infection risk of household contacts is 10 times higher than other contacts, and SARS-CoV-2 is more transmissible than SARS-CoV and MERS-CoV in households 22 . Studies suggested that infected individuals can transmit the virus efficiently within household via droplets, fomites, aerosol and faecal contamination 23,24 . Moreover, household transmission of SARS-CoV-2 is very efficient because the virus can survive up to 9 hours on human skin and can remain viable for up to 72 hours on plastic surface and stainless steel within the household confined space [25][26][27] . Conducting immediate contact tracing and control measures were important to contain this outbreak in Kuala Terengganu district. The implementation of immediate lockdown of BKMQ when first case was diagnosed in which no one can go in or out of the institution had prevent further transmission of the virus in the community. Cancellation of social gathering and daily disinfection within BKMQ had also successfully prevent further cases within BKMQ. All confirmed COVID-19 cases from the institution were immediately isolated and admitted to hospital for treatment, including symptomatic occupants who were not detected as positive yet. Inter-agencies collaboration is utmost important in the implementation of lockdown of BKMQ and deterring SARS-CoV-2 transmission in community 28 . Kuala Terengganu District Health Office had obtained continuous assistance and cooperation from various governmental and nongovernmental agencies during the lockdown period of BKMQ. Numerous challenges were faced during the COVID-19 outbreak in BKMQ. Firstly, there was some degree of difficulty in isolating the residents to their own place as most of them were sharing living spaces in the institution, while no one patrol inside the institution constantly. Next, most of the occupants were teenagers with no local social support as they originated from all over Malaysia and abroad. Language barrier is another challenge faced when dealing with non-Malaysian occupants. As a newly emerging disease, COVID-19 outbreak in BKMQ had also led to fear of being infected, tremendous stress and anxiety to the ground level officers and front-liners who were deployed to take care of BKMQ occupants on daily basis. While there were about 400 occupants that needed to be locked down in the institution for 7 weeks, Kuala Terengganu District Health Office also need to manage other COVID-19 cases detected outside of the institution. This high burden of workload and mental stress led to exhaustion of manpower and the morale of work, as well as depletion of resources such as personal protective equipment and transports. However, constant communications, coordination and assistance from other agencies had provided great relief to medical and health personnel in containment of COVID-19 within BKMQ and from further transmission in community. This had successfully contained the COVID-19 outbreak to only six positive cases in BKMQ among 400 occupants.

Conclusions
In conclusion, outbreak management in an institution requires prompt decision and action to contain the outbreak from getting worse. Immediate lockdown of BKMQ managed to contain the spread of COVID-19 from six cases to the rest of 400 occupants. Inter-agencies collaboration during the outbreak had successfully curbed the transmission of virus more effectively and relief the burden on healthcare personnel.