Catching infectious diseases in foreign workers before they spread
As a developing nation, Malaysia's economy is heavily reliant on foreign labour, who play a vital role in supporting several of our economic sectors.
Currently, foreign workers are sourced from 15 countries for seven critical sectors, which are manufacturing, construction, domestic work, agriculture, hospitality and services, mining, and farming.
As of December 2024, the Immigration Department reported over 2.3 million foreign workers in the country, making up 14.6% of the total workforce.
The government's policy under the Twelfth Malaysia Plan 2021-2025 (RMK12) is to cap the proportion of foreign workers at no more than 15% of the total national workforce.
According to data from the Human Resources Ministry (as of Sept 30, 2024), the majority of foreign workers are employed in the manufacturing sector, with a total of 771,327 individuals, followed by construction (698,407), and hospitality and services (448,572).
With so many of them here, health screening for foreign workers is not only essential for their personal well-being, but also important in our public health management strategy.
This is where the Foreign Workers Medical Examination Monitoring Agency (Fomema) comes in.
'Somebody needs to screen them so there is reduced risk of infection to our community.
'Delayed detection could lead to outbreaks, increased healthcare strain and potential risks to the local population,' says Fomema's medical division general manager Dr Mohd Ridzal Mohd Zainal.
Prior to arriving here (legally), all foreign workers have to pass a medical examination at the source country.
Dr Mohd Ridzal explains: 'After the medical screening, they are permitted to go back home until their permit is approved to work in Malaysia, so during this gap period, they can contract an infectious disease because they are not being quarantined.
'Bear in mind, those who are here legally also mingle with illegal or undocumented workers, so there is a risk of getting infectious diseases.
'Guidelines from each source country are different from ours, hence annual medical screening has been mandatory since December 2023 so we don't miss any diseases.'
Tuberculosis tops list
Once they arrive here, these workers have to go for another comprehensive medical examination conducted at Fomema-appointed clinics, which includes a physical examination, blood/urine test and chest X-ray to detect tuberculosis (TB).
Fomema screens for eight infectious diseases that create the biggest impact on public health.
If the workers pass, they can proceed to get their work permit.
Last year (2024), Fomema's records show that there were more than 15,000 cases of communicable diseases, with TB being the most prevalent, followed by hepatitis B and filariasis (see pie chart above).
'The data includes newly-arrived cases plus those who are already here.
'The cases among new arrivals are fewer because the government has imposed a strict quota on the number of new arrivals.
'Although less than 1% of foreign workers have been diagnosed with these eight diseases, there is still a risk as they could transmit them to others.
'If we detect the diseases through our medical examination, the workers will be deported,' says Dr Mohd Ridzal.
Due to governmental sensitivity, he is unable to share which countries the foreign workers typically afflicted with infectious diseases usually come from.
But the top three diseases and their source countries have been consistent since 2021.
He says: 'TB is endemic in these countries; Malaysia is also endemic for TB, but the percentage is small.
'If they have active TB, we treat them first before sending them back as they are infectious to others.
'But if they have latent TB (non-active), we send them back immediately.'
He points out that detecting TB via a chest X-ray is globally accepted and cost efficient, although the interpretation must be correct.
The X-rays are monitored digitally by Fomema's radiologists via their X-ray quality control centre.
'If the quality indicator is not met, we will instruct the panel to redo the X-ray.
'Most TB transmission is through a cough, i.e. the respiratory system, so if they have active TB, the bacteria will travel from the lungs to the mouth and into the air.
'Latent TB has the potential to become active and we don't know when that will happen, hence those with latent TB are not permitted to work in Malaysia,' he says.
Having said that, Dr Mohd Ridzal adds that those with a previous Covid-19 infection could also have scarring in the lungs, so if the doctor is unsure whether the scarring is due to TB or post-Covid infection, Fomema refers the case to a specialist to confirm diagnosis.
'For hepatitis B, we detect it every year.
'This viral infection causes no or few symptoms, so if the workers don't go for screening, they don't know they have it.
'The detection of this disease helps alert the foreign worker and guides employers on appropriate follow-ups.'
Detection does not necessarily mean active disease or transmissibility, but it allows appropriate treatment to be administered before they are repatriated.
Burden of 'new' disease
Filariasis was included in Fomema's health screening in December 2023 and quickly shot to the third spot the following year.
'We were quite shocked at the numbers and realise the burden is there.
'It's a disease where their leg starts to swell because there are worms inside,' says Dr Mohd Ridzal.
Filariasis is caused by several round, coiled and thread-like parasitic worms belonging to the family Filariodidea.
This parasite is transmitted by various mosquito species, including those in the genera Culex, Anopheles, Coquillettidia, Aedes, Mansonia and Ochlerotatus, depending on the geographic area.
Most of these vectors are present in Malaysia.
There are different types of filariasis, with the common one being lymphatic filariasis (LF), also known as elephantiasis.
According to the World Health Organization (WHO), infection is usually acquired in childhood and causes hidden damage to the lymphatic system.
The painful and profoundly disfiguring manifestations of the disease – lymphoedema, elephantiasis and scrotal swelling – occur later in life and can lead to permanent disability.
People affected by LF are not only physically disabled, but also suffer mental, social and financial losses, contributing to stigma and poverty.
In 2023, 657 million people in 39 countries were living in areas that require preventive chemotherapy to stop the spread of infection.
Dr Mohd Ridzal says: 'The treatment for filariasis is part of a global programme in collaboration with our Health Ministry and WHO.
'However, we have not established it yet so we have to repatriate them until the programme is established.
'Once the treatment begins and the worm is dead, foreign workers can continue working in Malaysia.'
Similarity with locals
For non-communicable diseases (NCDs), the trend is similar to our Malaysian population with diabetes, heart disease and hypertension (high blood pressure) topping the list. Signs of active TB (within red circles) can be seen in this chest X-ray. — Fomema
Dr Mohd Ridzal says: 'I think when they come here, they follow our culture, and eating and lifestyle patterns!
'If they have diabetes, then we have to make sure it is controlled – we are not so hard on them if they can manage it well.
'There is a process we follow, and if the diabetes is still uncontrolled or worsens, then they cannot work.
'However, for communicable diseases, we have to take swift action, report the disease to local health authorities to carry out contact tracing, etc – just like during the early days of Covid-19.'
Overcoming challenges
Some of the challenges in tackling communicable diseases include unsuitable/unhygienic living conditions, e.g. in restaurants and rumah kongsi (shared facilities) with poor ventilation.
Dr Mohd Ridzal says: 'TB treatment is free for everyone, but foreign workers are unaware of this, or maybe they are afraid of the consequences of losing their job if they get treated.
'There is also a risk of losing their legal status for those with latent TB so they try to avoid the system – sometimes, it's difficult to get them to undergo treatment as they run away.
'The danger of the disease itself becoming an outbreak is more than the cost of treatment.'
If they go for an X-ray, they can get treated for active TB, but their chances of getting a work permit is gone.
'We're still trying to improve our system to see how to overcome this because we need them to grow our businesses,' says Dr Mohd Ridzal.
One suggestion is to allow those with latent TB to work, but monitor them every few months, while those with active TB can get a conditional work permit after completing treatment.
Fomema's pre-screening results are confidential, but once the foreign worker is diagnosed with a communicable disease, he or she is unfortunately blacklisted.
In the works is an app for foreign workers to manage health conditions such as diabetes.
'When you ask a foreign worker what is his address, he doesn't know, so we are working with the Home Ministry on how to locate them so we can do the contact tracing faster in the event of a communicable disease.
'We also need to have safety awareness among employers because having a healthy lifestyle is important for every worker,' he concludes.
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