This is a retrospective description of processes involved in repatriation of Malaysian citizens from various countries during the Covid-19 pandemic. This descriptive report is registered under Malaysian National Research Registry (NMRR) with the research number NMRR-20-1508-55829.
Between February to April 2020, the Government of Malaysia directed repatriation of its citizens from China, Iran, Italy and Indonesia. The Mission was led by the National Agency for Disaster Management (NADMA), with the Ministry of Health (MOH) as its technical advisor. The mission had one primary objective to repatriate as many citizens based on aircraft capacity without endangering the safety of everyone on board the flight and back home in Malaysia. All passengers repatriated will be sent to a designated Quarantine Centre for a duration of 14 days.
Our team is divided into three - the Flight Team, the Reception Team, and the Surveillance Team. The operations were divided into four phases: pre-boarding screening, boarding and in-flight management, reception, and surveillance. Our team and pre-flight preparations from the first mission to Wuhan on 3rd of February 2020, was already in line with WHO recommendations (8). Figure 1.0 provides a brief description of the actions involved at each phase of response.
The Flight Team personnel consist of minimal airline crew required for the aircraft, an official from NADMA as the Mission Commander and medical personnel from the MOH. Based on needs, other support team members include Immigration Officer and officers from the Ministry of Foreign Affairs (MOFA) will be included. Medical personnel from MOH comprises of Emergency Physician, Public Health Physician, Nurse, Assistant Medical Officer and an officer from the Occupational Safety and Health Unit.
All Flight Team personnel undergo briefing on inflight safety procedures and use of personal protective equipment (PPE). Use of PPE differed between members of the team based on their seating location and work requirement.
Our Medical Team besides preparing infection control equipment, also brought along medical emergency resuscitation equipment such as transport monitor with defibrillation capability, transport ventilator and portable ultrasound. All equipment brought were ensured to meet flight safety standards.
Citizens must register with the Malaysian Embassy of the affected country for repatriation. The Malaysian Government does not mandate the need for swab test prior to flight. Directions were given to the citizens to keep hand-carried luggage to only one light weight backpack as to reduce boarding and disembarkation time. A hygiene kit was prepared at each seat containing a Health Declaration Form, minimum of three pieces 3-ply face masks, one hand sanitizer and a yellow biohazard labelled-bag.
Boarding and In-Flight Management
All repatriates were required to wear face masks and sanitize their hands upon boarding the flight. Visual triaging was performed by medical personnel stationed at the entrance of the aircraft to identify those who appeared unwell or required special assistance. Identified repatriates were tagged and seated closer to the medical team.
Seating arrangement considered the ability to provide distance between repatriates, separation of symptomatic and asymptomatic, and segregation from flight crew. The aircraft was divided into three zones - clean, exposed, and contaminated zones. These areas were demarcated with coloured tape for ease of identification and movement restrictions. Based on feasibility and flight capacity, two-row buffer rule of empty seats between zones was implemented to reduce risk of transmission (9). Lavatory facilities for passengers in the Clean Zone and Contaminated Zone are separated.
The cockpit and Flight Crew area was kept clear from the repatriates. The exposed zone is the area where the repatriates passed through during boarding. The contaminated zone is area where the repatriates are seated and usually extends to the rear end of the aircraft. Seating at this zone begins with asymptomatic repatriates, followed by symptomatic repatriates and lastly medical personnel.
Our team used personal protective equipment during the flight, even though our protocol had a two-row empty seats between zones. It was a practice started from the first mission and continued for all missions. There are several reports from previous PHEIC outbreaks that transmission may occur outside of the two-row rule (9–11).
Together with airline Flight Crew, we prepared announcement scripts regarding the flight, implemented seating arrangements, importance of frequent hand-sanitization, use of face-mask through-out the flights, minimization of movement during flight, location of dedicated lavatory facilities for passengers and importance of getting assistance for any health-related issues during the flight. All of these factors was regarded as factors that may contribute towards spread of infection during flight (12, 13).
Light meals during flight were only prepared for flight duration of more than five hours. Type of meal was prepared by the individual airlines.
The Reception Team personnel consist of officials from NADMA, personnel Fire and Rescue Department as Ground Mission Commander and medical personnel from the MOH. Medical personnel from MOH comprises Emergency Physician, Public Health Physician, Nurse, Assistant Medical Officer, Pathologist and Laboratory Technician. The team utilises the Air Disaster Unit (ADU) as base of the operations. The team is tasked to perform second triaging to identify and segregate symptomatic repatriates or those requiring special assistance to MOH-assigned hospitals.
Passenger disembarkation process occur in several groups of 40 into a bus that will ferry them from the aircraft parking bay to the ADU. Passengers seated in the Clean Zone were the first group to disembark, followed by the symptomatic repatriates, asymptomatic repatriates and lastly the flight crew and medical team seated at the rear of the aircraft.
At the ADU, all repatriates undergo several processes beginning with decontamination, health screening, screening swab test and boarding of the bus that will ferry them to a designated surveillance centre. Our reception protocol followed the two-step process of identification of potential repatriates at risk of symptoms, followed by isolating for secondary evaluation and testing at designated hospital (14).
Decontamination process involved the changing of clothing from civilian attire to patient attire. Non-perishable personal items were sanitized and sealed to prevent contamination of clean areas. The change of clothing to a patient’s attire assist in identification of repatriates from other personnel in the ADU. Six-lanes were set up for decontamination to minimise crowding and waiting times. Fast track lanes for the elderly, children and responders were made available.
After the decontamination process, symptomatic repatriates or those requiring special assistance are segregated and transported to designated hospital. Other repatriates then undergo a swab test before boarding a bus to the designated Surveillance Centre. Repatriates are provided with meal packs prior to boarding of the bus.
The Flight Team had to undergo similar process as the repatriates except for swab test upon arrival. Swab test was only performed if any were symptomatic. However, the mission to Indonesia we made it compulsory for the Flight Team to be tested on arrival. This mission is unique and considered high risk as the repatriates are mostly religious studies students and previous border entry screening for travellers from the area had high percentage of positive results. In all mission the Flight Team had to undergo a 24-hour stay in the designated Surveillance Centre.
The objective of the Surveillance Team is to perform daily health surveillance for presence of the infection for 14 days prior to home discharge. Repatriates will remain for a period of 14 days in the designated centres. During their stay, symptomatic and repatriates tested positive on first swab were isolated and sent to designated hospital for isolation. Besides getting access to healthcare needs, repatriates were also provided with Mental Health Psychosocial Service (MHPSS). The pandemic together with travel restrictions imposed by governments creates many uncertainty and anxiety (6).
Since the Government of Malaysia does not mandate stranded citizens in foreign country to have swab test done prior to registration for flight; there is a risk that infected repatriates may be asymptomatic upon entry screening (15). A repeat swab done on day 13 and results made available prior to discharge to home.