Malaysia’s Covid-19 Epidemic: What’s Next?

By Dr Lim Teck Onn |

To avoid another costly lockdown, we must now do two things well: mass vaccination and mass screening.

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About three months ago, I reported in these pages on the Covid-19 situation in Malaysia in the midst of our second wave. 

A lockdown was imposed again in January (MCO2), and with the Covid-19 new case count coming down in the past weeks (see chart above), the lockdown is just beginning to be lifted.

Many of my fellow Malaysians must be wondering what’s in store for us next? Is this the beginning of the end of our war against Covid-19?

It Is So Predictable, What’s New Then?  

Given enough time, all lockdowns will work, and so does MCO2. The number of new Covid-19 cases has decreased, much to everyone’s relief. Sure, one may dispute the count has decreased in part because we are doing less testing. But there can be no dispute that MCO2 has worked. 

When one is prepared to lock down a population and restrict them from mingling, whether at work or at play, virus transmission will certainly decrease, but at the cost of much mental anguish and damage to the economy. It is simply not sustainable and must be lifted sooner or later.

Prevalence and Outcomes of SARS-CoV-2 Infection Among Migrant Workers in Singapore.

The second wave of Covid-19 in Malaysia is predicated on three factors:

  • Asymptomatic or pre-symptomatic transmissions which typically account for less than 50 per cent of infections [1];
  • Super-spreading or clustering of transmission, by which 20 per cent of infected individuals cause about 80 per cent of transmissions [2];
  • Presence of a large number of migrant workers working and living in crowded conditions. The last factor accounted for the large outbreak in Singapore last year, which was successfully contained. They have subsequently published their data (see figure above), confirming 56 per cent of workers in dormitory were infected, of which only 22 per cent were symptomatic and only one died (0.001 per cent).

Given that these three factors are still here with us (MCO2 did not eliminate them), let’s not pretend the worst is over.

What’s next then? Let’s hope we have use the time so dearly purchased with MCO2 to prepare for the next phase of the war.

To avoid another costly lockdown (MCO3), we must now do two things well: mass vaccination and mass screening.

Mass Vaccination

Vaccine works. Data from Israel [4] (the first country to implement population-wide vaccination) has confirmed it works in the real world too, not just in clinical trials. Vaccine doesn’t just protect us individually; emerging data suggests it could stop transmission and prevent asymptomatic infection [4,5], thus herd immunity is achievable, given enough people are vaccinated in a population.

There is no time to waste. Malaysia failed to join the rank of Asia-Pacific countries which have successfully suppressed Covid-19 through public health measures alone [6].

Unlike these countries, we don’t have the luxury of taking our time to roll-out the vaccine (Interestingly, Singapore has started vaccination since January 2021, despite being relatively Covid-19 free). 

Our government now has a second chance to prove its mettle to the rakyat; that all who want to be immunised will receive their shots soon (the anti-vaxxers and vaccine-hesitants can wait till 2022 or later).

Covid-19 will return as the MCO2 is being wound down, so we must follow in the footsteps of the UK, US, Israel, India and Indonesia.

These are countries which were unable to completely suppress Covid-19. They have all rolled out the vaccine, and their performances have set a benchmark for us (see table below).

Our prime minister was the first person to be jabbed in Malaysia on February 24, and as the chart below shows, about 250,000 front-liners have received their first dose as of March 11.

Our government has set itself a target to jab 26 million people (80 per cent of the population) by the end of 2021. This is a reasonable and achievable target, by no means the fastest schedule in the world (The US did about 20 million a month, and the UK seven million a month), but let’s not raise expectations too high.

To meet this target, our government will have to ramp up the vaccination rate quickly, to the tune of 2.7 million people vaccinated per month till year end. 

The private health care sector should be roped in to assist in this massive efforts; they are eager to do their part. Non-conventional delivery channels like pharmacies, on-site vaccination at factories, colleges, etc. should be considered too. 

No less critical is community engagement and messaging to get all Malaysians behind this effort. All must do their part in this war against the virus.

Mass Screening 

Covid-19 will return as the MCO2 is being lifted; businesses are reopening, schools have resumed, even social life will start to pick up. Humans are just naturally social, it is not just in our culture) but in our genes too.

All places where large numbers of people must unavoidably congregate repeatedly and often for a prolonged duration, such as factories, offices, workers’ dormitories, old folks’ homes, schools, college dorms, army barracks, or even cruise ships, are potential hotspots for rapid Covid-19 transmission.

We know better than most countries, having repeatedly observed many Covid-19 clusters arose first from factories and other workplaces.

Two ways to screen to prevent the spread of the virus: temperature check, which will work if all who are infected have symptoms. and screening test.

We must change our testing strategy from one focusing on case diagnosis and test and trace to a mass screening strategy. All the abovementioned potential hotspots should implement this.  

The idea behind mass screening is simple. Detect the infection early and prevent the person from spreading the virus to others. We are already doing this; everywhere you go, you will have your temperature checked. 

This is symptom screening, which unfortunately doesn’t work because as shown by data from Singapore, only 22 per cent of infected workers there had symptoms [3].

Mass testing works, and it works fast. Indeed, some factories or even offices are already doing this. Unfortunately, most employers could only do this bi-weekly, or at worst, monthly, which really is useless, but understandable as current PCR or even RTK antigen testing using nose swabs is technically demanding and hence costly. 

Source: Rezaei M, et al. Point of Care Diagnostics in the Age of COVID-19. Diagnostics 2021, 11, 9

It is also uncomfortable and hazardous (swabbing causes sneezing, which discharges potentially infectious droplets). PCR tests also have long turnaround times, which compromises the efficacy of screening.

Like vaccine, advances in medical technology have come to the rescue. Low-cost technically undemanding rapid tests which could be self-administered (much like home urine pregnancy test) have become available.

New tests based on new (LAMP, Hybrid capture, CRISPR, etc.), or not so new technologies (spectroscopy) which could be conveniently performed on saliva, breadth or saline mouthwash, are emerging too. High frequency mass screening is now technically possible and affordably feasible.

Source: Mina MJ et al. COVID-19 testing: One size does not fit all. Science  08 Jan 2021:Vol. 371, Issue 6525, pp. 126-127 DOI: 10.1126/science.abe9187

It is important to bear in mind that for the purposes of mass screening (as opposed to diagnosis of individual patients), test accuracy (measured by test sensitivity or false negative percentage) is much less important than test frequency and turn-around time. 

Diagnostic testing requires very accurate test (sensitivity 95 per cent or higher), but paradoxically, a test with say 70 per cent sensitivity but performed frequently is superior for screening purposes. 

This is because current screening tests based on PCR or RTK Ag are too costly to be conducted frequently. Even well-to-do employers can only afford to do these tests bi-weekly at most, which is insufficient. 

A low-cost (say RM20 per test) less sensitive (70 per cent) test conducted twice weekly will beat a highly sensitive (99 per cent) test performed once every two weeks (Overall sensitivity of twice weekly testing is 99.19 per cent).

References

  1. Ferretti  L, et al. Quantifying SARS-CoV-2 transmission suggests epidemic control with digital contact tracing. Science 368, eabb6936
  2. Adam  DC, Wu  P, Wong  JY,  et al.  Clustering and superspreading potential of SARS-CoV-2 infections in Hong Kong.   Nat Med. 2020;26(11):1714-1719
  3. Tan IB, Tan C, Hsu LY, Dan YY, Aw A, Cook AR, Lee VJ. Prevalence and Outcomes of SARS-CoV-2 Infection Among Migrant Workers in Singapore. JAMA 2021;325: 584-585
  4. Dagan N, Barda N, Kepten E, et al. BNT162b2 mRNA Covid-19 vaccine in a nationwide mass vaccination setting. N Engl J Med. Published online February 24, 2021. doi:10.1056/NEJMoa2101765
  5. Del Rio C, et al. COVID-19 in 2021—Continuing Uncertainty. JAMA Published online March 4, 2021
  6. Patel P, Sridhar D. We should learn from the Asia–Pacific responses to COVID-19. Lancet Reg Health West Pac. 2020

Dr Lim Teck Onn is formerly a consultant nephrologist and director of the Clinical Research Centre. He is currently involved in clinical and health research in collaboration with the Ministry of Health, universities, and industry.

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