Table 3 summarizes the evaluation findings based on type of hazard and its possible work activity involved where exposure from it could result in safety and security issues, assessment of the risk based on its description dan rating that uses color coding to categorize the risk as well as considering the adequacy of risk control that has been implemented.
The management for COVID-19 especially among illegal detainee has opened a different perspective that goes beyond its clinical management per se. In the case of illegal detainees, depending on who sees what and how, there is always an argument on the complex balance of security needs between human rights and appropriate health care that need to be provided to these group of population (12). One must remember that first and foremost, these detainees has an offence of having stayed in the country without legal documentation while some of them have additional violation such as criminal offences and has been convicted by the local court. As security is defined as a state where measures are taken to protect a territory, person, infrastructure, or organization, against any possible threat, this fall under the purview of the nation sovereignty in terms of legal authority on the country and its population. On that note, under the European system, it has been stated that in emergency situations, authorities may require to take measures that normally diverge from the standard human rights protection (13).
In standard practice, detainees in custody is given medical care of the same quality and standard as is available to the public. Nonetheless doctor-patient consultation should always be preceded with a safety risk assessment to ensure treatment could be given in a safe manner (14). As such this paper concentrates on presenting security related issues that were assess in managing detainee patients. The HIRARC evaluation that was used is an integrated methodology, aiming to be more transparent to cover people, property, environment, and reputation of the organization. Overall issues that were identified as posing additional risks can be broadly categorized into four (4 types) of hazards which are physical, biological, psychological and ergonomics hazards. Description details of each hazards is as below:
Physical hazard
With the ever-evolving challenge in managing pandemic situation, reports have commented that in general detention centres and its system has lack of medical access which may affect the optimum provision of good healthcare. It is especially dire for people in such facilities, given that exposure to the virus can lead to relatively quick and life-threatening consequences. As in general it may be difficult to comply with local health guidelines such as practicing frequent hand washing and physical distancing, both due to access and supplies (15). This is one of the reasons why PKRC was transformed to provide the same medical care as any human being. However, with such facility of new and unfamiliar infrastructure it could pose as potential physical hazard. This type of hazard is considered as being more relevant since risk may come from threats related to breakout/escape, riot, aggression, or self-harm from detainee. Even though data and the actual number these incidences among detainees is not readily available statistically, however it is well known to occur. One reason why healthcare facility is seen as an opportunity for escape route is the perception that security control is lax. Concurring to this reasoning was one rational why evaluation found that physical hazard gained the highest total risk rating of 25 for people, asset, and reputation. It was also the main concern for all security related agencies with the risk of bodily injury from handling potential riot, hostage or strike incidents. This situation even became a great concern as the number of inpatient detainees reached up to 400 at one time.
The countermeasure adopted uses the concept Defence in Depth (DiD) where a series of defencive mechanism are layered to protect what should be protected and in the case of PKRC, it is the people and asset. When implemented correctly and maintained properly, defence in depth leads to a reasonable level of security. Therefore, mitigation that was put in place by collaboration with various agencies included a four-level security which are:
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First level – This is implemented in the red and yellow zones where immigration officers has the authority to guard this group of people through the function of a special tactical team that act to contain immediate unwanted incident and to bring other staff out to safety.
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Second level- This is in the form of a 24-hour standby police team as well as the use of approximately 2 km length of concertina wire that surrounds the facility in enhancing reinforcement to the first line defence mechanism.
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Third level – Approximately 13 allotted control posts guarded by a combined team of police, military and RELA (People Volunteer Corp) that goes on watch 24/7 located outside the concertina perimeter.
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Fourth level - The last defense was in the form of regular on wheel patrol by both the police and security officers of the Agro park itself.
In addition to having multilayer security level, other mitigation included was having repeated number of practical simulations for riot scenario as well as having ongoing medical related dry run that could lead to potential unwanted incident to occur. This simulation exercise was done at different shift and place to reflect the possibility of any unwanted event that can occur anytime and anywhere within the facility. This was also done to strengthen the command, control, and coordination among multiagency.
Biological hazard
With the ever evolving in the pandemic situation, reports have commented that in general detention centres and its system has lack of medical access which may affect the optimum provision of good healthcare. It is especially dire for people in such facilities, given that exposure to the virus can lead to relatively quick and life-threatening consequences as well the difficulty in complying to the local health guidelines (2, 15).
As such, the government has decided that these infected detainees received medical care at this low risk quarantine and treatment centre or commonly known as PKRC. Based on the whole operation, more than half (59.6%) of COVID-19 positive detainees had a clinical staging of category 1 and 2 which are asymptomatic and symptomatic with no pneumonia (16). The assessment was done based on zoning area of the facilities that was divided into three zones; i.e red, yellow and green zones as per Fig. 1. The zoning was decided based on the distance of exposure from COVID − 19 positive patient, clinical/work activity and protective infrastructure that has been in place for example, glass shielding as a separator. For medical care, each cubicle ward (4 metre width, 12 metre length) houses 4 to a maximum of 6 patients with ample space clearance as well as necessities being provided for personal care and hygiene. The whole area has in total 36 cubicles with a total bed capacity for 216 patients. As part of preparedness should there be a surge of cases, the area can house up to another 34 beds to full maximum capacity of 250 beds This subsequently translate to the type of personal protective equipment that is needed to be worn when working in each zone.
Based on rating, the highest score was found to be 20 and as such, those working in the red zone that deals directly with detainee and has higher risk and were mandated to wear full PPE which include Tyvek suit, N95 mask with face shield, plastic apron, shoe cover and double gloving as part of minimizing the risk. However, PPE has its own risk if not properly worn especially during doffing post shift. Therefore, the role of the infection control team in monitoring PPE procedure such as proper donning and doffing techniques was assessed periodically and on spot check basis. At the same time, PKRC also embarked on a health surveillance monitoring where those frontliners irrespective of agencies were randomly chosen to undergo nasopharyngeal/oropharyngeal swab testing for COVID-19 to assess for possible workplace exposure. Approximately 520 of them (representing nearly 50% of total staffing) were swabbed and all results reported were negative.
From another positive angle, while maintaining the right to non-discrimination and equality in access to healthcare and health services, this evaluation was also one approach to portray that the collaborative arrangement between agencies facilitate better preparedness in terms of managing security related issues so as not to disrupt health-care delivery within centre that cater this vulnerable group (17). Other danger that may arise was from the environment factor such as the existence of wildlife animals. This is not surprising as the surrounding area is an agritourism park resides on a 130 hectares of land belonging to the Malaysian Agricultural Research and Development Institute (MARDI). There was one incident reported where a frontliner while on his round duty, found a phyton in a manhole. This was probably due to weather condition where at that time, it was a dry and hot season where animal tend to seek hiding in confined spaces to reduce heat exposure. This was rectified by sealing all possible manhole. Thereafter, no incident was reported. Lesson learned from such pandemic is that it gives all security-related agencies to develop and/or strengthened their standard operating procedures in managing detainees with illness and in future become more prepared to handle such similar incidents.
Psychological hazard
As this is a novel pandemic, the management of patient without a doubt created a lot of anxiety, fear, and stress. This was related to the amount of workload, issues related to the new norm working environment such as having to use full PPE most of the time. In addition, as PKRC is unique in the sense that it caters for illegal detainees, other psychological issues that arose were the feeling of boredom due to certain monotonous activity such as guarding at the control post. The variety of the psychological spectrum was influenced by the role of different agency and the different work zone area where higher score was found from those working in the red zone with a score of 20 while working in the green zone such as guarding at control post has lower scoring 6 for rating score.
A cross-sectional comparative study that examined psychological distress, depression, anxiety, and stress experienced by 470 health care workers in Singapore during the COVID-19 outbreak between medically and non–medically trained hospital personnel (clerical staff, administrator and maintenance workers found that there were 68 (14.5%) participants screened had anxiety, while depression and stress were 42 (8.9%) respectively. The prevalence of the psychological impact was lower than those in the published literature from previous disease outbreaks and this could be due past Severe Acute Respiratory Syndrome (SARS) experience that improved mental preparedness and enhanced a more definitive infection control measure (18). With this known knowledge, PKRC set up a special unit to cater the mental health psychospiritual support (MHPSS) to all staff in need. The strength of people that operates this unit include psychiatrist, psychologist, counsellor, and religious expert from Ministry of Health and The Military Religious Corps. As part of formal services, pre deployment briefing and post deployment debriefing was given to all staff who worked at PKRC.
On the perspective of the detained patients a study postulated that the coronavirus pandemic could adversely affect the mental health of prisoners and further increase rates of self-harm, and the negative psychological effects of quarantine (19). Form patient’s perspective, this service was also provided but with more controlled environment. However, during the facility entire operation, there were no major violence occurred and care was given in a peaceful manner. This may be consistent with the finding that although numerous negative psychological consequences are associated with confinement and social isolation, spending time in this makeshift facility has probably reduced prisoners’ exposure to negative and intimidating behaviours, such as bullying, threats and violence from other inmates. This was even considered as a privilege of having a conducive therapeutic environment, thus increasing their overall sense of safety and security (20).
Ergonomics hazard
One of the daily activities that has potential to cause health ill effect was related to food distribution and serving to patients due to its regular repetitive motion in order to distribute 3 times meal a day to 400 existing detainees’ patients in a period of 45 minutes for each meal session. This activity must be completed by 5 staff per shift where 2 persons works in the yellow zone while the remaining 3 works in the red zone. At the same time due to security issues related to illegal detainees, this job scope had to be modified with the use of artificial intelligence. Through observation, packed foods were brought into different zone in ward using different method where from the green to yellow zone until the entrance of red zone, food was transferred using manual procedure with the aid of trolley. Thereafter from red zone, food was distributed directly to patients using robotic equipment thus minimizing repetitive motion. This modification also eliminates manual handling and renders the category of risk as low with a rating score of only 4. At the same time, the use of this locally developed robotic technologies in distributing the foods have help mitigate the risk of infection due to proximity.
Based on the whole assessment, an infographic in Fig. 2 was drawn to represent the combination of the overall HIRARC findings. The infographic not only depict in terms of risk level but also be explained in terms of the extend of risk based on width of area. Another way to make the infographic better is to use the common color coding of risk where red represent high risk, yellow as medium risk and green colour as low risk. It was found that physical hazard has all three-risk level with high risk representing the biggest perimeter area as possibility to physical injury from security issues in managing illegal detainees remains a constant priority issue. This was the reason for the multilevel DiD was put in place. Vice versa, risk from exposure of COVID-19 patients as biological hazard was given as low risk with the widest perimeter area as the prevention and control measures that has been adopted was able to minimize the risk of cross infection. There was still possibility of high and medium risks especially in the red sone working area but with good control measures such as the use of PPE, distancing practice was able to bring down the risk to level lower. Similarly, ergonomic hazard was also given low risk with the use of artificial intelligence that eliminated manual handling and repetitive motion. Generally, with the current assumed prevention and control methods used has facilitated the government and public health practitioners in tackling safety and security issues among all staff as well as managing morbidity among these marginal group. At the same time, involvement through multi-agencies approach remains relevant as it lessens the work burden and does not overwhelms the overall healthcare services (21). Even though the semi-quantitative risk rating was done during a period that had certain preparedness level, risk remain an uncertain which may need to be assessed in terms of frontliner man power strength, the number of existing detainee patients in ward and the evolution of the COVID-19 infection. In summary, this type of infographic presentation will not only facilitate organization to visualize the combination of existing hazard, its risk level as well as a check and balance approach for assessing the prevention and control measures in place, it also can be used for mapping out and comparing the dynamic in changes of the risk through snapshot of times.
