Reflections On The Covid-19 Pandemic At Two Years – Dr Adeeba Kamarulzaman

Fixing the health system to put us in readiness for an Omicron surge and other potential new variants is doable; the harder part is addressing the structural and systemic problems, whether it’s urban poverty, our treatment of migrant workers, or prison overcrowding as a result of punitive drug laws.

For those of us who read ProMED-mail, a publicly available internet service that reports on emerging diseases and outbreaks, the news on December 30, 2019, of a cluster of pneumonia of unknown aetiology, possibly related to contact with a seafood market in Wuhan, China, triggered a small alarm.

Could this be a re-emergence of SARS or H1N1 flu or other similar respiratory disease? At the University Malaya Medical Centre (UMMC), my colleagues and I in the Infectious Diseases Unit discussed the report with some trepidation, memories of SARS, Nipah, and H1N1 still fresh in our minds.

On January 9, 2020, the World Health Organization (WHO) reported findings from an investigation by the Chinese Center for Disease Control and Prevention (China CDC) of a novel coronavirus, identified in a hospitalised person with pneumonia in Wuhan. By January 10, Chinese researchers deposited the full genome sequence in GenBank and publicly released their findings. Since then, almost every country, rich or poor, big or small, has not been able to escape unscathed and the world as we know it will never be the same again.

To date, more than 281.5 million cases and 5.4 million deaths from Covid-19 have been reported worldwide, although The Economist estimates that the actual toll is 18.6 million people with a 95 per cent chance that the true value lies between 11.6 million and 21.5 million additional deaths. Malaysia has recorded 2.7 million cases and more than 31,000 deaths to date.

Two years on – from the speed at which the virus was identified (the virus causing SARS was identified some four months after the first cases of atypical pneumonia was reported) and the genomic sequence shared, which enabled diagnostic tests to be developed – to the number of vaccines that have been developed and approved and given to 3.77 billion people around the world and the availability of effective treatment for early and severe disease, one can say that medical science has delivered.

Yet, as we stand at the cusp of the second anniversary of the Covid-19 pandemic, we are still not at the state of the endemicity that we were hoping to be in just a few months ago, or are we? The emergence of a new and highly transmissible variant dampened this hope and as of December 25, a total of 62 cases due to the Omicron variant have been reported in Malaysia.

Several studies have confirmed the increased transmissibility of the Omicron variant compared to Delta. In a study from the UK Health Security Agency published on December 10, the household secondary attack rate with Omicron was estimated at 21.6 per cent compared to 10.7 per cent with Delta. Thus, it stands to reason that there are probably many more cases in Malaysia than currently identified or reported.

Reassuringly, recent reports from countries that have seen large waves of infection due to Omicron suggest that it causes milder disease, most likely due to a combination of lesser virulence of the virus, a younger group of people who have been infected as in the case of South Africa, and the presence of a high degree of immunity – either due to natural infection or vaccination.

However, because of the incredibly high transmissibility of the virus, there is no room for complacency, but on the other hand, there should also not be a reason to panic, especially here in Malaysia where 97.6 per cent of the adult population and 78.4 per cent of the total population have been vaccinated and the booster vaccination programme is well underway.

Both laboratory and real-world data show that although two doses of the vaccine may not provide adequate protection against Omicron, booster doses lead to between 60 per cent and 75 per cent effectiveness against severe disease.

Aside from ensuring that we achieve as high a booster coverage as we did with the primary vaccination program, what else can we do to ride this wave of Omicron? Given the ease by which it spreads, access to rapid testing would be key, as is re-educating the public on the symptoms of Omicron (which resembles more of the cold rather than “the classic three” Covid-19 symptoms of fever, cough, and loss of sense of smell or taste associated with earlier variants), on the need to self-isolate if infected, and on keeping up with masking and distancing.

Importantly, ensuring that the health system is adequately prepared this time around is crucial. Many gaps in the system were identified and lessons were learnt from the devastating Delta surge seen all across the country between the months of July and October this year which crippled the district health offices (PKDs) and the acute care hospitals.

Decades of underinvestment in the public health system meant that our public health teams were unable to respond to the surge of infections in a timely manner due to an outmoded disease notification system, lack of automation, and inadequate human resource to adequately perform contact tracing and isolation to break the chain of transmission.

On the clinical side, earlier and better coordination and cooperation between the government primary care system and private general practitioners and the public and private hospitals could possibly have averted many deaths, especially cases of brought-in-dead. As it stands, as of December 28, 2021, Malaysia’s confirmed death toll from Covid-19 is 31,369 or 958 per million population, which represents the highest rate of confirmed death in the ASEAN region, three times that of Vietnam and Thailand and approximately twice that of Indonesia.

But perhaps the greater lesson to be learnt from the Covid-19 pandemic in Malaysia is the need to seriously and urgently address the underlying factors that saw at least three groups of the population disproportionately affected by the pandemic.

Large numbers of cases were reported from the urban poor living in congested dwellings, refugees, migrant workers both documented and undocumented, and prisoners. The Covid-19 pandemic amplified the cracks in our society and the health-related problems that have existed in each of these populations for a very long time.

Given the airborne spread of the virus, with their crowded poorly ventilated dwellings, each of these groups was in a state of disadvantage to begin with. Adding to it, the inability to adequately isolate and quarantine to prevent others from becoming infected.

Secondly, low rates of health literacy and in the case of migrant workers, language barriers resulted in incomplete understanding of disease transmission and measures to prevent it. Particularly for migrant workers, a lack of access to basic health services meant delays in diagnosis and access to care, whilst high rates of diabetes and obesity in the low-income group predispose them to more severe Covid-19 disease.

Fixing the health system to put us in readiness for an Omicron surge and other potential new variants is doable, and a transformation of the health system to confront future pandemics is not only essential but inherently possible.

The harder part is addressing the structural and systemic problems, whether it’s urban poverty, our treatment of migrant workers, or prison overcrowding as a result of punitive drug laws.

Are we as a society ready and importantly, do we have the political will to take a deep look at ourselves and truly confront these large societal issues? Or are we already fatigued and ready to move on, and just like the annual floods, only deal with it when the next flood or pandemic strikes?

It would be an affront to those who lost their lives to Covid-19 and more recently to the floods if we take a business-as-usual approach in 2022 and beyond to not at least acknowledge and try to address some of the structural issues, social injustices, and inequalities that exist all around us.

Dr Adeeba Kamarulzaman is a professor of medicine and infectious diseases at University Malaya.

Dr Adeeba’s article is part of an exclusive series of guest essays by experts in the health care sector for CodeBlue on their reviews of Malaysia’s 2021 Covid-19 response and their outlook for 2022.

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