The Consistency of Islamic and Medical Perspectives in the Control of the COVID-19 Pandemic

Controlling the current COVID-19 pandemic requires infection control at both the individual and global levels. There is insufficient information on the consistency between Islamic principles and medical guidelines regarding infection control measures. Therefore, this study aimed to explore the consistency between Islamic principles and evidence-based medical recommendations during the pandemic time. A comparison was made between the latest medical infection control recommendations and Islamic references (the Quran and its interpretation, and Sunnah and its explanation). Relevant materials such as books and research articles in Arabic or English were Ulum Islamiyyah Journal | Special Issue: Healthcare in Pandemic Era: “The New Norm” Vol.3 2 reviewed. The information was then classified into different levels of infection control strategies, which were individual, household, community and healthcare unit levels. This study demonstrated that both Islamic principles and medical guidelines are consistent in terms of infection control, which involves crisis supervision by the infection control authority and specialised agencies, hand and general hygiene, personal protection, seeking specialist consultation and treatment, comprehensive care, guidelines in the event of limited resources, home isolation, travel bans and quarantine. Moreover, it was observed that Islamic principles combine and optimise both the individual frame and societal cohesion.


Introduction
Since the World Health Organization (WHO) declared the COVID-19 outbreak a pandemic on 11 March 2020, the pandemic has recorded more than 173 million infections and 3.7 million deaths by 6 June 2020 (Ducharme, 2020). The spread of the causative virus, SARS CoV-2 from one person to another occurs mainly via respiratory droplets and aerosols, hence, airborne precautions are recommended when aerosol-generating procedures are performed. Moreover, an indirect transmission may occur when the infectious droplets contaminate the environment, thus, environmental disinfection is also an essential component of preventing the spread of COVID-19 (WHO, 2020a). Aside from medical advances and evolution, the role of religion in the global COVID-19 crisis should not be underestimated. This is because according to the report issued by the global religious landscape, 84% of the world population in more than 230 countries and territories are religiously affiliated (Hackett et al., 2012). Among the different religions, Islam is the second-largest religion in the world, with over 1.9 billion followers which accounts for 24.1% of the world population. Statistics also showed that Muslims make up the majority of the population in 49 countries (Pew Research Center, 2017). It is, therefore, imperative to highlight the consistency between Islamic principles and medical recommendations during this pandemic. Hence, this study aimed to explore the consistency between Islamic principles and evidence-based medical recommendations during the pandemic.

Methodology
The latest medical recommendations for infection control were identified and compared against Islamic references, including the Quran and its interpretation, and Sunnah and its explanation. Relevant materials such as books and research articles in Arabic or English were reviewed. A comparison was conducted between Islamic perspective (IP) and medical perspective (MP) on several key aspects of infection control, including crisis supervision by the infection control authority and specialised agencies, hand and general hygiene, personal protection, seeking specialist consultation and treatment, comprehensive care, guidelines in the event of limited resources, home isolation, travel bans and quarantine. Lastly, the obtained information was classified into different levels of infection control strategies: individual, household, community and healthcare unit levels.

Results and Discussion
Each of the infection control aspect is discussed from the MP and IP as below.

Crisis Supervision by the infection control authority and specialised agencies
MP: Infection control authority and specialised agencies are set up for supervising the COVID-19 crisis at the national and international levels (Centers for Disease Control and Prevention [CDC], 2020a).
IP: The Quran has recorded that regulations should be established to govern the dissemination and sharing of information during a crisis. It is stated that individuals should not disseminate or share any information unless the information has been referred to and validated by the Messenger or the respective authorities; those with sound judgment would have validated it (Alkassimi, 2020b;The Noble Quran, n.d.).
From both the MP and IP, the establishment of supervision teams is deemed necessary and is encouraged. In fact, practices of infection control supervision have been incorporated in Islam since the beginning.

Hand hygiene, general hygiene and personal protection
MP: The WHO has been continuously emphasising the importance of the five moments of hand hygiene, face covering and the sequence for donning and doffing of personal protective equipment (PPE) in preventing the spread of COVID-19 (WHO, 2020a).
IP: It was narrated in Sahih Muslim that handwashing is a crucial step for cleaning and should be done by rubbing three times between the finger joints. Besides, it is recommended to perform the handwashing practice immediately after waking up as no one knows what the hands have touched while sleeping (Sahih Muslim). Generally, hygiene and purity are considered two of the noble attributes of Muslims by both the Quran and Hadith. For instance, the Hadith states that "Cleanliness is half of the faith" (The Hadith-b, n.d.) and the Quran states that "Indeed, Allah loves those who keep themselves clean and pure" (The Qur'an 2:223). Muslims are encouraged to practise handwashing (part of ablution) before and after meals, upon exiting the toilet, and after touching dirty or harmful items or surfaces (Islamweb, 2019). Clothes cleanliness is also emphasised in the Quran as God likes to see His servants dress well in purified clothes (Khan, 2020). Muslims are required to perform ablution, which involves washing their hands, mouth, nostrils, face, head, upper arms and feet three times, before performing their prayers. With at least five times ablution daily, the Islamic standard of cleanliness is higher than the handwashing requirement from the MP. Moreover, the Islamic teachings in Sahih Muslim also recommend ten major acts of cleanliness, such as nasal irrigation with water, nail cutting, armpit hair removal, shaving pubic hair and cleaning the private part after voiding (Khan, 2020). Apart from cleaning for dirt, sexual intercourse, menstruation, postpartum, and other reasons (Alkassimi, 2020b).
The data implied that from both the MP and IP, hand hygiene, general hygiene and personal protection are essential pillars in fighting infections. However, in Islam, hygiene practices are more of a regular daily routine rather than a specific short-term measure for infection control. Hence, Muslim communities tend to adapt faster to the recommendations and regulations from the infection control authority.

Consulting specialists and seeking early medical treatment
MP: All medical recommendations emphasise the importance of early consultation and providing true and correct information to the relevant specialists, and warn against the consequences of inaccurate disclosures and delay in seeking consultation and services (Chow et al., 2020).
IP: Similarly, consulting specialists and seeking early medical treatment are also in line with the Islamic teaching, as highlighted in the Sunnah. Also, the Quran advises that for any unknown occurrences, Muslims are required to consult those who have the specific knowledge -"If you do not know, ask the knowledgeable" (The Qur'an 16:43). In Islam, Muslims are encouraged to seek medical advice with an integral approach and all permissible means, with confidence that Allah SWT facilitates a cure pathway for every disease.
From both the MP and IP, it is agreeable that consulting specialists and seeking early treatment are essential and crucial in medical care. While the IP recommendations urge the principle of seeking medical treatment and advice from the qualified and specialists, the MP regulates those specialists through licencing.

Comprehensive care, including social, financial and psychological support for patients and families
MP: In pandemic control, medicine nowadays stresses comprehensive care which involves a multidisciplinary team, with the inclusion of financial, social and psychological supports for the patients and their families (Miethke-Morais et al., 2020).
IP: Islamic approach of public health practices involves offering free medical treatment and financial aid for all during a pandemic, as practised by the influential caliph Omar bin Al-Khattab. Islam encourages people to stay positive, do their best, remain stable and hopeful, and believe in God's will throughout the journey of overcoming their illness. This kind of psychological state helps to boost the immune system in fighting illnesses. Moreover, the teachings of Sunnah encourage Muslims to support each other and show solidarity during a tough time. For example, Sahih al-Bukhari encourages Muslims to say optimistic words and one of the related verses is "There is no 'Tiyarah' (superstitious beliefs in bad omens), but I like a good mention." Besides, another verse in Sahih Muslim states that "None of you believes until he loves for his brother what he loves for himself" (Alkassimi, 2020b). In general, Islam considers the individual, society and community charity as the basics of spiritual support to the needy during crises. The balance between the individual and community needs are fundamental to Islamic beliefs. The support, compassion and help offered by individual Muslims to the needy in the community will become the basics of spiritual guidance within the community (The Hadith-c, n.d.; Alkassimi, 2020a).
In short, considering comprehensive care for individual patients, families and communities as the best way to support them against epidemics is agreed by both the MP and IP.

Guidelines in the event of limited resources
MP: As reported by the WHO, in the event when PPE become limited due to high patient volume or any other reasons, strategies such as cancelling non-urgent procedures or visits and offering home care when appropriate should be implemented. Besides, inpatient strategies are also crucial to control the spread of infection when encountering a shortage of PPE (Bauchner et al. 2020(Bauchner et al. , 2020. Examples of inpatient strategies applicable for the COVID-19 pandemic include limiting movement outside the patient room, prioritising the use of specific PPE for the highest risk situations, designating the entire unit within a facility for the care of known or suspected patients with COVID-19, minimising face-to-face contact with the patients, excluding nonessential personnel and visitors from entering the patient room, limiting the number of people who examine the patients, using medications with extended intervals to reduce nursing encounters, and assigning a health provider for telephone interviews with hospitalised patients. Moreover, alternatives of a specific PPE should be considered as well to overcome the supply shortage. For example, elastomeric half-mask, full-facepiece air-purifying respirators and powered air-purifying respirator can be alternatives for N95 masks. Furthermore, cautious and limited reuse of PPE with decontamination may be reasonable when resources are limited. According to the CDC, a face mask may be used for 8 to 12 hours (Bauchner et al., 2020). Healthcare providers should avoid touching or removing their mask between patient encounters since the outer surface of the mask is presumably contaminated. If the provider touched the mask, they must immediately perform hand hygiene.
IP: Islamic guidelines in the event of limited resources involve righteous cooperation and Ashura between the specialised team and the community. In the event of unprecedented difficulties in terms of resource supply or measures implementation, all stakeholders should be consulted to ensure the benefits of the community is prioritised (Cairo, 1955) In situations with limited resources, both science and religion should be considered to provide optimum service to the community. The IP relies on the expectations technique, avoids evil is more significant than that brings benefit and seeks higher benefits and lower harm (Egypt Dar Al-Ifta-Dar Al-Ifta Al-Missriyyah, n.d.).

Travel ban, home isolation and quarantine
MP: Movement control order, border control and travel bans have been practised by most countries globally as the infection control measures during the COVID-19 pandemic (Daim & Povera, 2020).
IP: It was recorded that travel restrictions and quarantine have been in place since the early days of Islam to prevent the spread of illnesses. Regarding this, the Prophet Mohamed said, "If you get wind of the outbreak of plague in a land, do not enter it; and if it breaks out in a land in which you are, do not leave it" (As-Salihin, n.d.). In other words, a sick person is prevented from going outside of the infected area, and at the same time, healthy individuals are prevented from entering the infected area as well. Omar bin Khattab replied about the Prophet's order not to enter the plague area; when asked, are you afraid, he said no guarantee from God's decision, but we must obey God's regulations (Hadith Encyclopedia, n.d.).
Both the MP and IP recognise travel ban, home isolation and quarantine as infection control strategies. In the current COVID-19 pandemic, COVID-19 patients with no or mild symptoms and those suspected of COVID-19 who are awaiting test results should strictly adhere to these strategies. Patients or individuals under a travel ban, home isolation or quarantine must stay away from other people and animals, and home visiting should be restricted. If the patients or individuals need to be in close contact with others, they should wear a face cover. A medical mask is recommended, however, if not available, a cloth face cover should be used. If the patients or individuals require the services from caregivers, the number of caregivers around the patients or individuals should be limited. The caregivers should remain six feet apart from the patients or individuals in the house when possible and should also wear a face cover. Besides, the caregivers should use a separate bedroom and bathroom from the patients or individuals if available and the shared spaces in the house should have good ventilation. The caregivers should always practise hand hygiene: after contact with the patients or individuals or their immediate environment, the caregivers should not directly touch the patient body fluids (Feng et al., 2020). Also, the caregivers should be trained on the proper way of using PPE. Sharing dishes, drinking glasses, cups, eating utensils, towels, bedding with the patients or individuals should be avoided, and the items should be cleaned separately after each use. Disposable gloves should be worn when handling these items. Lastly, thermometers should not be shared or should be thoroughly disinfected before use by other household members (Alkassimi, 2020b;CDC, 2020c).

Integrated infection control strategies in the community
Some examples of integrated infection control strategies in the community include practising diligent hand hygiene, respiratory hygiene (e.g., covering their cough), general hygiene and cleanliness (Khan, 2020;Mohamed, 2014;WHO, 2020a). In fact, this kind of hygiene and cleanliness practices are required in Islam as a daily routine. Furthermore, social distancing should also be practised in the community. Unless it is for essential activities, otherwise people should stay at home. If leaving home is necessary, people should maintain at least a six-feet (two-metres) distance from others, practise contactless greeting and wear a face cover (Adams, 2020). Besides, close contact with ill individuals should be avoided. Also, routine cleaning and disinfection of environmental surfaces with products approved by the Environmental Protection Agency is a crucial infection control strategy in the community (WHO, 2020a). If there are positive or suspected cases in the community, people with no or mild symptoms should be self-quarantined at home for isolation and visiting is not permitted. This is crucial for breaking the transmission chain in the community. Throughout the quarantine or isolation period, sharing of food, drink, clothes, towels, personal hygiene items, tableware and drinkware should be avoided. The Islamic perspective roles stated, paying the damage is in advance of bringing the benefit (Egypt Dar Al-Ifta-Dar Al-Ifta Al-Missriyyah, n.d.).

Integrated infection control in healthcare units
All healthcare workers should wear PPE for standard, contact and droplet precautions. A level 1 and level 2 PPE can be used around regular patients for respiratory droplets or even airborne precautions. A level 3 PPE (plastic apron, jumpsuit, hood and mask, goggle, double gloves, boots, boots cover and eye or face protection) should be used when dealing with suspected or confirmed COVID-19 patients. Hair covers, goggles and disposable face shields should be used to cover the hairs and face (front and sides). Shoe covers should be used when the healthcare workers are in high-risk areas such as a dedicated COVID-19 ward or intensive care unit as the floor surfaces may be contaminated by the COVID-19 virus. Also, changing and disposing of the shoe covers when leaving such areas are necessary to prevent cross-contamination. Furthermore, all healthcare workers should be trained in proper donning and doffing of PPE as errors in equipping PPE may transmit the virus to the healthcare workers (Okamoto et al., 2019). In Islam, guidance is to follow the specialised one in his career, and if you don't know, say I don't know. The Muslim must seek wisdom whenever available (Aboul-Enein, 2016;Mahmoud, 2015).
The integrated infection control domains have proven that both medical and Islamic perspectives covered the whole areas and circumstances of the pandemic.

Conclusions
Studies showed that infection control measures had been incorporated into Islamic practices as a regular daily routine with experiencing multiple pandemics in the past 1,400 years. Hence the reason why there were no inconsistencies found when comparing the MP and IP on infection control in this study. Furthermore, Islam optimises both the individual frame and societal cohesion. Nevertheless, future studies are recommended to include a systematic review using a predesigned data extraction form to further analyse and advance the knowledge related to the topic.

Acknowledgement
The authors wish to thank Associate Professor Asrar Abubakar (Department of Paediatric, IIUM) and Associate Professor Mohamed Hasan Elnaem (Clinical Pharmacology, Kulliyyah of Pharmacy, IIUM) for their valuable inputs in this study.