The first case of Covid-19 in Malaysia was reported on 25 January 2020. The number of cases increased from 29 on 1 March 2020 to 99, 428, 1306 and 2,470 on 8, 15, 22, and 29 March respectively and 3,333 and 3,483 on 3 and 4 April respectively. The numbers increased 120 times within five weeks.
The claim by the Health Ministry on 1 April 2020 that the cases were beginning to plateau has not materialised with 208, 217 and 150 new cases reported on 2, 3 and 4 April respectively. The fatality rate as at 4 April was 1.64%.
Data Is Critical
As the outbreak continues, information is required to ensure that the population and positive persons are managed in the best possible way. This information includes the natural history of human infection, routes of spread and transmissibility, the populations at risk, successful clinical practices in managing positive persons, laboratory information in diagnosis and screening and genetic information about the virus e.g. sub-type, mutation etc.
There is much that is known about COVID-19 from reported data, mainly from China, but there is much more that is unknown.
Some of the information is available; some are not whilst much is emerging in real time. Such information helps to refine responses to the outbreak.
There are many pieces in the jigsaw puzzle of the knowledge of Covid-19 and its management. Some are being fitted together by WHO and other international organizations. Whether their emerging information is applicable in the Malaysian setting is a moot consideration.
Inter-country comparisons are fraught with challenges with different demographics, health systems etc. Some have compared Malaysia with Italy, which has a fatality rate of 12.07%. The rationale for such comparison is unknown.
There is no reply, as yet, to questions about comparisons with Asian countries like China, South Korea, Singapore, Japan and Taiwan.
Taiwan is an interesting example. Despite its close proximity to China, the prediction that there will be an epidemic there did not materialise.
According to the Johns Hopkins University Coronavirus Resource Centre, there were 348 cases on 4 April 2020 with 5 deaths i.e. a fatality rate of 1.44%.
It is not rocket science to acknowledge that the Malaysian response to Covid-19 has to be based on Malaysian data, as it cannot be assumed that the disease profile in Malaysia is the same as in other countries particularly with the diversity in our population.
World Health Organization Global Surveillance
The World Health Organization (WHO) has a global surveillance programme with a detailed reporting format for member countries to provide detailed information about every positive person (Accessed 3 April 2020).
Malaysia, as a member, provides such information to WHO.
Malaysian data about the Covid-19 outbreak is sparse. Apart from the daily menu about the number of cases and deaths, and more recently, “hot” areas and tests done, there is no detailed data.
The clinical features of the Covid-19 positive patients are not available to clinicians at the frontline, although respiratory complaints constitute a substantial number of cases seen daily by general practitioners in private and public clinics.
It was reported that the Selangor Task Force for Covid-19, has urged the Health Ministry to share data on the outbreak to help it make data-driven decisions.
The Director General of Health was reported to have stated on 31 March 2020 that “Statistics point to people from the age of 26 to 30 years and from 56 to 60 years as the most number among those found to be Covid-19 positive…Those in the 26-30 age group could be Malaysian students or others who have returned from abroad and those in the 56-60 age group could be the heads of households who have to leave home often to buy essential goods.”
Better Quality Information Needed
General practitioners and other clinicians at the frontline need much more than such information to enable them to make better assessments of persons who have influenza-like or other symptoms and/or travel history and their contacts.
For example, abdominal ache, diarrhoea and loss of taste and/or smell have been reported in positive persons. However, they are not included in the 5th edition of the Health Ministry’s clinical guidelines which define a case as someone with an “acute respiratory infection (sudden onset of respiratory infection with at least one of: shortness of breath, cough or sore throat) with or without fever AND travelled to / resided in foreign country within 14 days before the onset of illness, OR close contact in 14 days before illness onset with a confirmed case of COVID-19, OR attended an event associated with known Covid-19 outbreak.”
Clinicians at the frontline need much more detailed information about the clinical features of the Covid-19 cases in Malaysia to improve their screening, management and advice for persons who have influenza-like, gastrointestinal or non-specific symptoms as they could be Covid-19 suspects.
Information about the clinical and other features of the positive persons should be made available not only to doctors, nurses and other health care professionals, but the public whose involvement is critical to success or failure in containing the outbreak.
Public health specialists and researchers need, among others, information about:
• Transmission dynamics i.e. modes of transmission (role of aerosol transmission in non-health care settings and role of faecal-oral transmission); viral shedding in various periods of the clinical course in different biological samples i.e. upper and lower respiratory tract, saliva, faeces, urine (before symptom onset and among asymptomatic cases; during the symptomatic period; after the symptomatic period / during clinical recovery);
• Risk factors for infection – behavioural and socio-economic risk factors for infection in households/ institutions and the community; risk factors for asymptomatic infection; risk factors for nosocomial infection among health care workers and among patients;
• Testing – what tests; focused or mass testing etc.
Analysis of the reports to WHO and other information about the infection in positive persons would provide information that answer some, but not all, of the above questions. Ongoing analysis and new information will provide real time information for a disease which knowledge is still evolving.
Well analysed data should be shared with the international community to expand knowledge about the infection.
The shared information can also assist Malaysian organisations formulate their plans when the Movement Control Order ends, which approach should be science-based, risk-informed and phased.
The WHO Director General statement “You cannot fight a fire blindfolded. And we cannot stop this pandemic if we don’t know who is infected” is particularly apt.
Openness, Transparency And Public Engagement Crucial
South Korea has managed to stabilise the trend of the outbreak there. Its Foreign Minister stated in an interview by the British Broadcasting Corporation on 15 March 2020 that the “basic principle is openness, transparency and fully keeping the public informed.”
The public and health care professionals, who are all at the frontline, expect the same of the Health Ministry.
The Health Ministry has a duty to inform the public and health care professionals if they have any impediments to the sharing of information.
The Health Ministry cannot contain the outbreak without the involvement of health care professionals and the public. The earlier information is shared, the better the chances of containing the outbreak.
The war against the virus can only be won with science, which means information is shared with everyone, particularly health care professionals. Otherwise, the country may lose the war against Covid-19 although it may appear to win some battles.
Dr Milton Lum is a past President of the Federation of Private Medical Practitioners Associations, Malaysia and the Malaysian Medical Association. This article is not intended to replace, dictate or define evaluation by a qualified doctor. The views expressed do not represent that of any organization the writer is associated with.
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