Covid-19 was the worst public health disaster in Malaysia. The first case of Covid-19 was reported on January 25, 2020, and the second year of the pandemic was the worst.
According to the Health Ministry, there were 2,840,225 cumulative reported cases on January 25, 2022 compared to 186,849 on January 25, 2021, an increase of 1,520.0 per cent. Yesterday, cumulative reported Covid-19 cases rose to 3,040,235, including 21,072 new infections.
The cumulative reported deaths on January 25, 2022 were 31,918 compared to 689 a year before, an increase of 4,632.5 per cent.
Malaysia has the highest cumulative reported cases and deaths per million population in ASEAN, a statistic that no one can be proud of.
The errors in pandemic management – which included issues of testing; contact tracing; health care professionals; interaction with the private sector, universities and non-governmental organisations; comorbidities; migrant workers; standard operating procedures; risk communication; political instability and leadership – have been discussed previously (see here and here).
At the beginning of the third year of the pandemic, it is time for a review and reset of Covid-19 strategies. Some of the issues are discussed in this article.
Humility Needed
Humility is needed in the formulation of a reset of the national Covid-19 policy and strategies.
The SAR-CoV-2 virus has been very predictable with its unpredictability. The duration of immunity to the virus, either from vaccination or prior infection, is unknown. Whether more transmissible, immune evading or more virulent variants will follow Omicron is unknown. Whether SARS-CoV-2 will become a seasonal infection like influenza is known. Some antivirals have been ineffective in those infected with Omicron. Whether antivirals will prevent long Covid is unknown.
Knowledge about the virus, the host response and data will evolve. More tools to manage the virus will become available together with better understanding of its limitations.
However, it is likely that political instability and leadership issues will continue in Malaysia until the next general election when, hopefully, it will be resolved.
It is also necessary to be humble to accept that there is a continuous need to adapt to changing situations, with speed of response a critical factor.
Whilst modelling and predictions are necessary, they have to be evidence-based guesses but not mathematical certainties.
Public health, economic, and social functioning in Malaysia require the political and professional leadership to establish specific goals for Covid-19 management; benchmarks for public health measures; reforms and investments in health to prepare for future SARS-CoV-2 variants and/or pandemics; with clear strategies to achieve these objectives.
The goals and strategies of “living with Covid” have to be communicated clearly to the public as no country can be in a perpetual state of vagueness, confusion or emergency.
Testing and Tracing
Testing and tracing are among the foundations of the public health management of any infectious disease, and Covid-19 is no exception.
The test available are the polymerase chain reaction (“PCR”) test and the antigen rapid test kit (“RTK-Ag”). The PCR tests, which detect genetic materials of the SARS-CoV- 2 virus, are the gold standard.
The antigen tests (“RTK-Ag”) detect proteins on the viral surface and its results are more likely to be in concordance with positive PCR tests when the viral load is high as determined by the PCR test cycle threshold (“CT”) value, which is the number of amplification cycles of viral RNA.
The CT values are inversely proportional to the amount of viral load and more severe Covid 19. When the CT is less than 30, which is indicative of a higher viral load, the concordance with positive rates with the RTK-Ag tests is higher. However, the PCR results are presented as positive or negative and not in CT values.
What Is Malaysia’s Testing Capacity?
The Health Ministry reported a total of 181,238 tests, which comprised 87,780 PCR and 93,458 RTK-Ag tests, on 12 August 2021. During that epidemiological week, 140,501 Covid-19 cases were reported, with a total of 1,097,031 tests done, comprising 526,958 (48.3 per cent) PCR tests and 570,073 (51.97 per cent) RTK-Ag tests – the daily average was 75,280 PCR tests and 81,439 RTK-Ag tests.
The highest number of 90,293 PCR tests done was reported on August 19, 2021 (accessed February 2, 2022). Delays in diagnostic testing had a snowball effect on contact tracing and spread of the disease, rendering some of the test results of limited or no value in public health management.
It would be reasonable, with some degree of generosity, to infer that Malaysia’s daily PCR testing capacity does not exceed 100,000.
According to the Health Ministry’s modelling, Omicron could lead to a surge of 15,000 to 30,000 daily cases.
Would Malaysia’s testing capacity be sufficient for the current Omicron surge? With the current surge from Omicron, this has given rise to a view that screening for asymptomatic disease is no longer relevant. How will this impact on the spread of disease and public health management?
The Medical Device Authority (“MDA”) has given conditional approval to 116 self-test kits (accessed January 31, 2022). However, there is no public data provided on the kits’ user acceptability e.g., the ease of manipulating the kits’ parts and legibility of the printed instructions may lead to an inaccurate result or user anxiety about the accuracy of the result. There is also no public data on the real-world reliability of the various kits.
The sales numbers of the various kits are unknown. Surely the public, who purchase these kits, with many paying out-of-pocket, have a right to information about its reliability. What happened to consumer rights?
Malaysia needs a comprehensive testing and reporting system, which should accommodate the incorporation of tests at home, with a simple mechanism for self-reporting and real-time reporting on a public website. Needless to say, socio-demographic, vaccination, and clinical outcome data have to be anonymised and linked.
Everyone in Malaysia should have access to low-cost testing for screening purposes. These tests should be in plentiful supply and free or at low cost to help individuals, particularly the vulnerable, who might be infectious to avoid spreading the virus to others in their homes, schools, workplaces and other settings, and to get access to prompt medical attention if needed. All employers should fund such tests and ensure they are readily available.
Concomitantly, when the tracking system is notified of a positive test, it should automatically include the provision of clear and concise guidance on self-isolation; management of close contacts; and access to medical attention and treatment options, if necessary.
Contact tracing has to be expeditious, preferable within 24 hours, for it to be useful in public health management. The current methods of contact tracing, which are predominantly manual have to give way to digital techniques, particularly since the numbers from the Omicron variant are large.
It is a shame that the gene sequencing capacity of Malaysia lags behind that of less developed ASEAN countries like Cambodia. Malaysia has to beef up its gene sequencing capacity for it to be useful in decision making.
Surveillance
The emergence of the Omicron variant has emphasised the need for comprehensive and nationwide surveillance, which should include environmental surveillance like wastewater. Traditional surveillance is usually reactive which means it is usually too late to contain the spread of an emergent variant. A comprehensive national system should be capable of empowering state or local authorities with rapid, actionable data and enable prevention to be proactive.
Furthermore, a comprehensive genomic surveillance system will provide early data on the emergence of new variants and any immunity escape. This includes more widespread use to include the sequencing of breakthrough infections, even if mild. The benefits of real time databases include targeted resource distribution to slow down the spread of new variant(s).
There is also a need for real-time surveillance of the frequency and severity of the adverse effects of vaccination, breakthrough infections and waning immunity. The dependence on data from other countries is not prudent because of several reasons that include socio-demographics, public attitudes, vaccines used etc.
Non-Pharmaceutical Interventions
SARS-CoV-2 is spread by mainly by aerosols and sometimes respiratory droplets. Non-pharmaceutical interventions (“NPI”) continue to have an important role in limiting its spread as multiple measures, apart from vaccination, are needed to limit its rate of spread.
The Omicron variant spreads very easily with a doubling time of 1.5 to 3 days compared to the 6 to 8 days of the Delta variant. Many countries are encouraging usage of high-quality filtering facepiece respirators (“FFRs”) like the N95 or KN95 masks instead of cloth or surgical masks to reduce viral spread, particularly in crowded indoor settings.
However, cost has been an impediment for most people. There is a need for a government-led initiative to produce and ensure FFRs are easily available to everyone at very low cost or for free.
Another effective NPI is the upgrading of ventilation and air filtration systems, including use of outside air, efficient filters (minimum efficiency reporting value [MERV] 13 or more) and high-efficiency particulate air (“HEPA”) filtering devices. HEPA filters are more than 99.97 per cent efficient at capturing airborne viral particles associated with SARS-CoV-2.
Such ventilation systems need to be implemented in closed settings like offices, schools, restaurants, airports, public transportation etc. Owners should be incentivised to modify their premises to ensure that buildings integrate these upgrades.
Ventilation guidelines were issued by the Department of Occupational Safety and Health and the Human Resource Ministry in July to August 2021. However, the silence about its implementation, monitoring, and compliance is deafening.
Dr Milton Lum is a Past President of the Federation of Private Medical 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 organisation the writer is associated with.
- This is the personal opinion of the writer or publication and does not necessarily represent the views of CodeBlue.
