The Federation of Private Medical Practitioners’ Associations, Malaysia (FPMPAM) calls on the Government to institute, as soon as possible, mass treatment of early prima-facie COVID-19 cases as an addition pillar of action to break the chain of transmission. This is aimed to bring down the pool of infection to below critical mass, cut short the lockdown time and assist in the economic recovery of the country.
The claim that there is no strong evidence that chloroquine or hydroxychloroquine (HCQ) works for COVID-19 is currently being challenged by experts and governments around the world.
The revelation by the Director-General of Health Malaysia on 7 April 2020 indicating that the use of hydroxychloroquine has probably contributed to the improvement of hospitalised patients and lessen the need for ICU care was indeed very encouraging. He also said that HCQ have been prescribed for use in hospitalised patients as an off-label indication since the onset of the outbreak of the pandemic.
Hydroxychloroquine (HCQ) is already one of the recommended therapeutic options in the Management Guidelines from the Ministry of Health for hospitalized patients including for those with early COVID-19. This Malaysian guidelines is also similar to that used by the NHS in UK.
If HCQ is recommended, prescribed and expected to work for early disease in hospitalised patients, there is no reason why it will not work for early disease in non-hospitalized patients especially the walking-sick in community setting.
The Size of the Pool of Infection
The present trend with the number of positive cases breezing past 4,000, as on 8 April 2020, the number of people tested positive in Malaysia for the virus is expected to rise to predicted 6000 or more by mid-April 2020. However, this is just the tip of the iceberg as more and more hot spots emerge every week and with increasing red zones nationwide.
What is important is the current estimate of the size of the pool of infected cases which is not addressed actively.
It is clear that many more who are untested and asymptomatic also pose as a source of infection in the community.
The British Medical Journal has just published a study from China indicating that up to four-fifth of cases are asymptomatic. This would mean that the pool of infectious cases in Malaysia would have now easily reach tens if not hundreds of thousands.
To date, there have been no active community-based treatment intervention to reduce this pool other than by stay at home order, mandatory quarantine and admission to designated hospitals if tested positive.
Public health and MCO measures should not be based mainly on the trend of positive cases alone as it will mean a prolonged lockdown. Instead, decisions should also be based on other key performance indicators including reduction of the pool of infection with active community-based treatment.
On 26 March 2020, the FPMPAM had submitted a proposal to the Ministry of Health Malaysia (MoH) with a recommendation for a Private-Public Partnership (PPP) program to implement mass early treatment with HCQ for COVID-19 cases using existing nationwide GPs and primary care doctors.
The strategy for this PPP program is for early diagnosis and early treatment with HCQ for all prima facie cases of COVID 19 in the community.
It is aimed at reducing the size of the infectious pool to below critical mass whereby it will no longer pose as a major public health danger. This is the third pillar in breaking the chain of transmission and is aimed at supplementing the existing two pillars of testing and mandated quarantine plus social distancing.
The rationale and principle of this PPP program have received the support of many national medical bodies representing the GPs and specialists.
In support, the medical fraternity have also called for the MoH to set up the protocol for the diagnosis, treatment and supply of the medication to the private sector and for the GPs to provide the delivery of service in their clinics as the point of care.
To reduce the pool of infection, massive number of early cases will need to be treated in a very short time. This cannot be achieved in the current hospital-based setting.
There are at least 8000 GPs in this country. Each GP treating 10 to 20 cases of early COVID-19 daily will be able, in a short while, provide treatment for hundreds of thousands of early cases of COVID-19. Within a month they would be able to cover a million patient if the need arises.
Available treatment must be affordable, cost-effective and safe
Hydroxychloroquine is relatively cheap compared with other more expensive antiviral agents that are being tested. Side-effects of HCQ are few and well documented. HCQ is already being used as part of the treatment protocol in hospitals in this country and around the world.
GPs are already familiarized with the use of antimalarial medications and HCQ is no exception. GPs have been regularly prescribing antimalarial medications for travelers to malaria infested areas and are best positioned to take on this additional role to help fight this war. To wait for results of the more expensive and newer anti-viral agents pending completion of WHO- led trials is not fair for the rakyat and the country who now have to bear the medical and economic burden of the disease.
Even if these new medications are eventually proven to be effective, their cost will be astronomically and will not be affordable for countries like Malaysia. Will the makers of these medications subsidize its use in Malaysia?
The cost in delay will see us miss the golden hour where decreasing the size of the infectious pool can actively flatten the curve. We need to act as fast as possible.
The only other cost that can be foreseen is the additional cost of testing. Presently, it is mandatory to test all patients before treating. However, it must be appreciated that the cost of one existing test based on today’s pricing, will be more than the cost of providing HCQ treatment for 10 patients.
With regard to overall cost it is clear that treatment of a prima facie case in the community setting will be way below what it will cost in the hospital setting.
As a simple calculation if early diagnosis and treatment for 100 patients can prevent one patient from ending up in the ICU the cost saving in times of money and human suffering will be enormous.
What is urgently needed is also a readily available point of care test for confirmation or exclusion of early COVID-19 disease. The current mandatory hospitalisation of all positive and PUI patients is very costly and resource intensive and not sustainable when the number of patients escalate into the tens of thousands.
A Matter of Public Health and Economic Urgency
It is reasonable that at this time of dire public health emergency, prima facie diagnosis and presumptive treatment at point of care by our experienced GPs can be an acceptable standard of care.
Treatment of a large number of patients in a short time have the potential to bring the infectious pool to below the critical mass and help break the chain of transmission.
As an additional benefit, it will also modulate the progress of the disease and decrease the number of patients that will need to be hospitalised and who may finally need intensive care and ventilation.
Mobilise the GPs in this war
Up to today, the GPs are the under-utilized reserve force that is yet to be mobilized.
The public health care service cannot be expected to fight this war alone.
The 8000 or more GPs are well-located nation-wide and are the very front liners that should be actively mobilized, equipped with the protocol, the PPEs and the medications to address the issue of the pool of infectious cases in the community. We need to engage the infection in this front in Ground Zero.
The PPP proposal allows GPs to continue with their regular patient care to relieve the burden on the public system as well as contribute significantly to address on-going public health danger by early diagnosis and treatment.
When point of care testing is readily available, the GP clinics can also take on the role of post-infection surveillance and follow-up as well.
It is only reasonable that other than just participating in WHO-sanctioned trials for hospitalized patients which can only cater for thousands of patients, we should at the same time, roll out a mass HCQ based COVID-19 early treatment program to treat hundreds of thousands of patients, without further delay.
- This is the personal opinion of the writer or publication and does not necessarily represent the views of CodeBlue.