I have refrained from writing this advisory earlier because I did not want to add to any emotional concern and panic that is already present. But the coronavirus outbreak (Covid-19) has continued to grow internationally.
It appears that it is now a global problem and spreading rapidly. The head of the World Health Organization (WHO) Dr Tedros Ghebreyesus stated recently that it has reached a “decisive point” and has “pandemic potential” and raised the coronavirus threat assessment to its “highest level”. We would like to believe that we in Malaysia are protected or will be spared but to quote the WHO director: “No country should assume it won’t get cases, that would be a fatal mistake, quite literally”.
The experience in Italy and South Korea shows how it can spread rapidly in any nation, even a vigilant one.
It is not possible for any country to completely close its borders to all countries, with more than 50 countries with infections. We will have to return to some degree of normality in view of the enormous economic impact that most countries, including ours, are facing.
While we have worked very hard to keep the spread of this virus limited in our country, this is not true of the capacity of all countries. So we can expect to be re-seeded by the coronavirus from other countries periodically over the next few months or year, or have our people infected when they travel.
We can continue to screen all (universal) visitors and Malaysians at entry points to our country, but remember that studies suggest this has limited value. Some infected individuals may be asymptomatic or only be mildly ill and not show a fever (or fever may be suppressed by medication). Studies have suggested this mechanism only picks up about 50% of cases.
So it is time that we, jointly as a community, take concerted steps to minimise the impact of this virus that most likely will spread in every country in the world. We cannot wait until we have an epidemic locally. It takes time to prepare, not just the health services, which are already geared up, but the community, which is still not adequately prepared.
In offering advice, I will try and be ‘fact-based’, but much is still not known about this outbreak. For example the extent of community transmission, what percentage of cases are asymptomatic and can asymptomatic individuals transmit the infection. Hence some of the ideas here will be based on best available information.
The key is to reduce your risk as the virus spreads throughout the world. While the infection is not severe, a small but significant percentage will get quite ill and possibly one percent will die. It will be very disruptive to our lives.
Some people, generally the older ones and those with chronic medical problems may get severe infections, but the rest of us are likely to get a minor infection and recover. So we want to reduce the risk of getting infected as well as minimise the virus load, while waiting for some degree of herd immunity to develop in a community that will minimise or dampen the spread of this virus widely.
Vaccines are being developed but recognise that this will take some time before they are ready and also vaccines will not become available to everyone until production can be enormously ramped up to meet the global need.
Meal Times at Home and Outside
Eating together can pose a risk of transmission, especially with our lovely Asian style of sharing food. At this time it is advisable not to share food with another person.
It is best to have a spoon for every dish and use that to put items onto your plate and not take food directly from the dish with your spoon or chopsticks or hands. It would be good to do this both at home as well as when eating out.
This practice should be something that we should adopt as a lifestyle, in view that there may be other virus outbreaks in the future. When you go out to eat, bring your own personal chopsticks or fork and spoon.
Higher risk individuals may also want to consider bringing their own cups for drinks. Avoid using a straw for drinks unless necessary, perhaps for a person with a disability. Straws are picked up by the fingers of the person serving you and then put into your drink and then you put your mouth on the straw – a high risk event.
Some fast food outlets may offer you a covered straw. Our children need to be taught these hygienic practices, including not drinking out of someone else’s cup or licking a shared ice-cream.
Improved Hygiene Practices by Food Outlets/Shops
How well utensils are cleaned in shops, from the corner coffee-shop to the restaurant to the fast-food outlet, are of concern. Cups, plates and all utensils should be washed thoroughly between meals/patrons.
All food outlets should also aim to clean the table tops in between every customer. They should use an alcohol based spray (at least 60 per cent alcohol) to wipe the table. They should dispense with the habit of using a dirty, wet tablecloth that is often reused for the entire day. This wet table cloth can be a good virus transmitter. Use instead a paper kitchen towel that can be used once and then safely thrown in the bin.
If shops do not do this, we as patrons can try to clean the table top before we sit down to eat. Food-handlers and servers should consider the routine use of a transparent kitchen mouth shield (mouth or spit guard).
Some restaurants already have this in place but time to consider the routine use of this item in all outlets. They are not expensive and can be reused after cleaning.
What to do if You Become Unwell and Dealing with the Unwell Person at Home?
What to do if you develop a respiratory infection? It should be the responsible thing to tell your employer or your school or university and refrain from going back until you’re well. That means self-quarantine yourself when you are unwell.
All employers should be sensitive to this and offer compassionate leave as well as the opportunity to work at home at this time. If one person at home becomes unwell, others should not sleep with them (this increases the virus load spread); there may be an exception for young children.
The ill person should also use a separate bathroom, if available. All ‘high-touch’ surfaces (example counters, table-tops, doorknobs, bathroom fixtures, etc) should be cleaned using a household cleaning spray or an alcohol-based wipe.
Generally we should avoid sharing towels and hanging them in the bathroom; damp towels are good items to spread viruses. All items for personal hygiene (towels, toothbrushes, etc) should be personalised i.e. individual use. Use closed bins at home for discarded tissues.
There is some evidence for this coronavirus to spread by stool (faeces). Flushing of the toilet should be done with the lid down and toilet bowl covers should be cleaned periodically.
How to Deal with Crowds, Conferences and Meetings?
It is best that we try to minimise contact with crowds, which is easier said than done. Try to keep your distance from individuals. Avoid shaking hands, hugging or touching others unless that is absolutely necessary.
It is best to postpone events that can be moved and avoid large gatherings as much as possible. This is not the time for celebrations, but only for essential meetings. Many medical conferences in the country have already been postponed.
Cough Etiquette and Dealing with Someone who is Coughing or Sneezing
Everyone should cough or sneeze into a tissue or learn how to cough or sneeze into a flexed elbow or sleeve, when it happens unexpectedly. After the cough or sneeze, dispose of the tissue in a closed bin and wash your hands with soap and water or clean your hands with an alcohol-based sanitiser (at least 60 per cent alcohol).
If someone in public is coughing or sneezing, keep your distance from them (at least 1 metre away), and ask them to do the above. If they are repeatedly coughing or sneezing ask them to put on a mask (3 ply surgical mask or N-95 mask).
Consider carrying some spare masks and offer them to individuals who cough or sneeze. We need to help others learn to be responsible. We also need to stop completely the habit of spitting in public.
Personal Protective Devices for Emergencies
It is important to carry our own personal protective devices for emergencies. Always carry some 3-ply surgical masks or an N-95 mask in your bag. We do not need to wear masks unless we are unwell ourselves or we are travelling in an enclosed environment with others, like an aeroplane, taxi, bus or train.
Remember that the 3 ply surgical masks or cloth masks are no longer effective once they are wet. They have to be changed frequently (at least hourly) and be worn correctly. Remember to dispose of them safely in a closed trash bin. It would be the responsible thing not to travel if you are unwell.
In addition, alcohol based hand sanitisers, with at least 60 per cent alcohol, are necessary to keep with you at all times. You should clean your hands after touching surfaces. Clean your hands with an alcohol-based sanitiser after you’ve left a shop or come out of an office, after touching door knobs, public tables, etc.
Of course the common advice, which is difficult to adhere to, is to stop touching your face with your hands when out of the home. Contaminated hands can transfer the virus to your eyes, nose or mouth.
Studies have shown that we touch our faces many times each hour and this increases our chances of getting infected. We need to support each other to reduce this behaviour of touching our face.
Dealing with Planned Visits to the Hospital or Clinic
Hospitals and clinics are higher risk locations to visit and we should avoid going to the hospital or clinic unless necessary. Many of us have planned visits for our chronic illness or we many need to visit a close friend or family member in hospital.
For planned appointments, it would be good at this time for hospitals and clinics to offer mobile appointment services, so that we can limit the number of people waiting to see a doctor in the clinic or hospital specialist waiting areas.
This would mean that we can arrive 10 to 15 minutes before the visit, see the doctor and go off quickly. This can be arranged if we improve the efficiency of our services at this time and may become a routine system to put in place for the future to limit crowds in clinic waiting areas.
Social Distancing Measures: Preparation by Schools, Universities and Employers
Those in education as well as employers with numerous employees firms need to prepare for a local outbreak; this means they need to have a contingency plan in place.
The responses from China, South Korea and Japan have been swift and decisive. For example they have closed schools for some duration but still are able to offer online education for the students. Iran has closed schools/universities and cancelled group Friday prayers in more than 22 cities.
Are we ready if we are faced with a similar situation? Are we prepared for temporary closures of schools and childcare facilities as well as workplace social distancing measures like teleworking and temporary closure of all religious meetings? Social distancing measures, if required, will be difficult for everyone but can be achieved if we all work together as a community and support each other.
Dealing with False Information
There are many false ideas and suggestions circulating and it is important we verify them before sharing with anyone. It is best to check with accredited sources or read reliable sites. WHO has a Covid-19 Myth busters page for advice for the public that is worth reviewing. For example, they state very clearly that, at present, there is no evidence that pets such as dogs or cats can spread this new coronavirus.
Also that it is safe to receive a package from China as coronaviruses do not survive long on objects, such as letters or packages.
Preparing Emotionally for an Outbreak
Often those in government and health services are concerned about any such outbreak, like the current coronavirus spread, but they will tell the public not to be worried. They do not want undue panic that can result in rash activities like panic buying, xenophobic behaviour, resorting to unproven therapies, etc.
We can understand this stance but we must get prepared emotionally for what might happen. It is important to act responsibly during this time. It would be good if we adopt, and continue to practice at all times, good infection control etiquette. We cannot act like we live on an island isolated from others. We should prepare not just for ourselves but also for our older family members and neighbours with chronic illnesses.
Our risk may be small but we need to prepare to lessen the risk for others, especially those who lack resources. Our preparedness and risk reduction will also reduce the burden on the health care system, allowing our medical staff to focus on those most vulnerable to this outbreak.
The situation is fluid and everyone needs to keep up-to-date with the latest information so that we can work, not just as a country, but a as a global community to deal with this threat. This outbreak will teach us many things about ourselves and the need for humanity to change and respect nature.
I leave you with these words of wisdom by Michael O. Leavitt, a former Secretary of the US Department of Health and Human Services, spoken in 2007 at a pandemic influenza leadership forum:
“Everything we do before a pandemic will seem alarmist. Everything we do after a pandemic will seem inadequate. This is the dilemma we face, but it should not stop us from doing what we can to prepare. We need to reach out to everyone with words that inform, but not inflame. We need to encourage everyone to prepare, but not panic.”
Dr Amar-Singh HSS is a senior consultant paediatrician.
- This is the personal opinion of the writer or publication and does not necessarily represent the views of CodeBlue.