Focused Protection From Covid-19

By Dr Milton Lum | 11 December 2020

At least three to four in every 10 Malaysians are at risk of severe Covid-19 and its mortality.

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It appears that Covid-19 is likely to stay in Malaysia for some time. The reasons are obvious i.e. community spread, significant asymptomatic cases, incidence of positive cases and deaths in poorer communities, large foreign worker population, imported cases etc.

The stark reality cannot be ignored. Even with vaccination programmes, it is unlikely that Covid-19 will disappear.

There have been repeated statements about getting to single digit or zero positive cases by certain dates. The dates came and went but the number of cases did not go away. Were the statements based on science or otherwise?

Who Are Vulnerable?

The clinical characteristics of 5,889 cases above 18 years of age admitted to 18 designated Covid-19 hospitals from 1 February to 30 May 2020 was published on 1 November 2020. There were 3,433 (58.4%) Malays, 391 (6.7%) Chinese, 135 (2.3%) Indians, 521 (8.9%) other Malaysian ethnic groups and 1,396 (23.8%) other nationalities in the cohort. Of the total cases, 5,418 (92%) had mild disease and 471(8%) had severe disease.

Of the 471 who had severe disease 329 (70%) were Malays; 57 (12.1%) Chinese; 21 (4.5%) Indians (21, 4.5%); 40 (8.5%) other Malaysian ethnic groups; and 23 (4.9%) other nationalities. There was contact history in 239 (54.7%), of which 16 (3.4%) were health care workers. 229 (48.6%) had hypertension.

“About 25% of admitted cases had at least one comorbidity, and 1,053 (20.0%) had history of medication for chronic diseases. Hypertension was the most common comorbidity (931, 15.8%) followed by diabetes mellitus (578, 9.8%) and asthma (196, 3.3%). About 496 (9.2%) active smokers had mild disease, while 33 (7.0%) had severe Covid-19 disease.”

“Older age (≥51 years), underlying chronic kidney disease and chronic pulmonary disease, fever, cough, diarrhoea, breathlessness, tachypnoea, abnormal chest radiographs and high serum CRP (≥5 mg/dL) on admission were significant determinants for severity.”

Covid-19 mortality statistics in Malaysia as of November 22, 2020. Picture from the Ministry of Health.

The Health Ministry disclosed data on 335 Covid-19 deaths as at 22 November 2020. For every 10,000 persons infected with Covid-19, 6 died with males exceeding females about 2 to 1. Senior citizens were more vulnerable with 64% of the deaths in persons aged 60 years and above.

Most of those who succumbed had co-morbidities i.e. high blood pressure in 61.4%, diabetes 41.3%, heart disease 24.1%, high cholesterol 19.1%, kidney disease 14.9%, and lung disease 10.6%. It was significant that 87% had at least one co-morbidity.

It is evident from the National Health and Morbidity 2019 Survey (“NHMS”) that many Malaysians have unhealthy health profiles. There is a high prevalence of the major risk factors for cardiovascular disease i.e. coronary artery disease and strokes.

One in five Malaysians i.e. 3.9 million aged above 18 years have diabetes. Three in 10 Malaysians have high blood pressure i.e. 6.4 million. Four in 10 Malaysians have high cholesterol i.e. 8 million adults. The NHMS estimated that 1.7 million Malaysians had all three risk factors and 3.4 million had two risk factors.

Unawareness of their conditions and poor or no control of the above three risk factors were common.

About half of the diabetics did not know they were diabetics. Only half of the hypertensives knew of their condition. 90% of known hypertensives were on medicines but the blood pressure was only controlled in 45%. One in four with high cholesterol did not know of their condition, with eight in 10 of those who knew taking medicines and of which the cholesterol was controlled in 63%.

From the aforesaid, it is evident that at least three to four in every 10 Malaysians are at risk of severe Covid-19 and its mortality.

The risk factors are age above 60 years, male gender, hypertension, diabetes, high cholesterol, asthma, and chronic respiratory and/or kidney disease.

Focused Protection

The non-communicable diseases (“NCDs”) of ischaemic heart disease, stroke, diabetes and chronic renal disease accounted for between 27% to 41% of disability and death combined in Malaysia in 2019.

According to the World Health Organization, Malaysia, as at 2019, had no operational multi-sectoral national NCD policy, strategy or action plan that integrates several NCDs and their risk factors. This incongruence is difficult to understand particularly when the NCD epidemic in the country continues unabated.

The Health Ministry’s targets are to reduce the prevalence of hypertension from 32.2% to 26.0%; halt the rise of diabetes and obesity; and reduce the risk of premature mortality from cardiovascular disease, diabetes, cancer and chronic respiratory disease from 20% to 15% (Source: National Strategic Plan for Non-Communicable Disease 2016-2025 page 14). However, the details of the roadmap are unclear.

In the light of the Covid-19 public health situation, what is needed is a definitive NCD roadmap with key transparent performance indicators to address NCDs and provide protection for those most vulnerable to severe disease and mortality.

The current Covid-19 situation is not surprising when the approach has been reactive – fire-fighting in lay language. Transparency and accountability cannot be replaced by inconsistency, illogical predictions, blame, and threats.

Such approaches only contribute to confusion, anxiety and fear, all of which do not promote public trust. Readers can make a judgement on whether there is a trust deficit.

The global strategies in the management of the Covid-19 pandemic are:

  • Widespread physical distancing to prevent spread
  • Widespread use of masks to prevent spread
  • Frequent handwashing or use of sanitisers to prevent spread
  • Staying home when sick
  • Widely available testing with results reported quickly
  • Large-scale contact tracing to determine who is infected, or may become infected
  • Targeted isolation of those who test positive for, or who have been exposed to, the virus
  • Focused protection for vulnerable persons

There is no single strategy that can control Covid-19. As such, a multipronged approach can address community spread; reduce related illnesses, long-term sequelae, and deaths; and mitigate its economic impact.

The adoption of proactive measures to protect every vulnerable person should be amongst the primary aims of the public health responses to Covid-19.

The risk factors for severe Covid-19 disease and mortality in Malaysia, known to date, are age above 60 years, male gender, hypertension, diabetes, high cholesterol, asthma, and chronic respiratory and/or kidney disease. It is known that when the co-morbidities are controlled, the risks for severe Covid-19 are much less.

As private sector clinics provide more than half the primary care for the population, they can be engaged to combat the NCDs of hypertension, diabetes and hypercholesterolaemia, and concomitantly, provide interventions that focuses on protection from Covid-19.

General practitioners can play significant roles in reducing the large numbers of the undiagnosed and poorly controlled NCDs within the parameters of a protocol acceptable to the health ministry and the doctors.

General practitioners have a closer relationship with patients compared to their public sector counterparts. This crucial factor alone will contribute to better screening, diagnosis, treatment and its compliance, and health education of diagnosed and undiagnosed cases of these NCDs. Besides, choice, accessibility and affordability have not, in most instances, been an issue with general practitioners’ services.

The additional measures needed would involve engagement with civil society. For example, assistance can be provided to the house-bound, particularly senior citizens and those with co-morbidities, with regard to sourcing of foods and other essentials of daily living. Where possible, they should meet family members outside rather than inside.

A flexible comprehensive list of measures, which include applications to multi-generational households, can be formulated jointly by public health professionals and non-governmental organizations, and implemented at local levels. This list is well within the scope and capability of any public health professional.

The above do not require much funds to protect the vulnerable from Covid-19 and the effects of the NCDs. However, what is required is public engagement, communication, time and above all, humility and commitment from all parties. In the longer term, there will be benefits for the individual(s) and the health care delivery system.

The harms of lockdown, which are increasingly evident globally but does not appear to have been considered by decision makers have already been addressed in an earlier article.

The impact of lockdown, with the variants of the Controlled Movement Order, on the health of Malaysians have yet to be published. Be that as it may, it is well known that income and health are intertwined.

It is time for the government to take a pause, re-calibrate Malaysia’s response to the true risk of Covid-19, make rational cost-benefit analyses of the trade-offs, and review the lockdown mentality, which is a simplistic and crude intervention.

There is an urgent need for the government to review its policies and strategies. In this respect, the appointment of an independent panel of experts will provide wider perspectives and options.

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.

  • This is the personal opinion of the writer or publication and does not necessarily represent the views of CodeBlue.
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