Insight - Endemicity and the economy, the dance in disease control

Considering the Malaysian prevalence of disease lies somewhere between 10% and 20% of the population, fully vaccinating the population is unlikely to terminate transmission of Covid-19 in the near future.

IT has been 611 days since Covid-19 was first reported in Wuhan, China. As disasters go, Covid-19 has been truly unprecedented.

The initial response that utilised aggressive public health and social measures (PHSM) has been framed as a trade-off between lives and livelihood.

Lombardy, Italy idealised this comparison in the early days- where a delayed response led to numerous mortalities.

However, it quickly became apparent that this juxtaposition was far more complex than previously imagined. The cost of controlling transmission was the plummeting of economies beyond the levels of the great depression and the crumbling of societies under the invisible walls of lockdown.

Notwithstanding, time and science have intimated the way forward. Effective governance led by science-backed PHSM has been critical in protecting both lives and livelihood. Supporting these measures with high levels of vaccination has also been shown to accelerate progress to recovery.

While, experts generally believe that the possibility of herd immunity against transmission of the disease remains unlikely with the first generation of vaccines – many countries have successfully begun the road to recovery by using this approach.

Nonetheless, the rise of mutant strains of SARS-nCoV-2 has unfortunately derailed much of this progress. Despite very little evidence suggesting immune escape of current circulating variants against severe disease – it has become clear that the increasing fitness of these strains are likely to allow active circulation of these strains within the immediate future.

Considering the Malaysian prevalence of disease lies somewhere between 10% and 20% of the population, fully vaccinating the population is unlikely to terminate transmission of Covid-19 in the near future.

Under the assumption that evidence-based disease control mechanisms are in place and vaccination rates will increase, Covid-19 will likely be transformed from a rabid killer into a much less deadly flu-like illness with periodic breakthroughs of infection within the immediate future.

This will be the road to disease persistence, the road to endemicity. Essentially this means that infections will continue to persist within communities, just like the flu. Hence, it will require the public health apparatus to continue monitoring the disease with clear thresholds for action, and clear actions if thresholds are passed.

The dance in disease control

Tomas Pueyo suggested that the PHSM against Covid-19 is like a dance, and the early lockdowns, a hammer. On current evidence, the hammer has been our weapon of choice against the pandemic resulting in the economy and society being unnecessarily imperilled.

If we are to successfully navigate endemicity, we must progress to control the disease with economic and social sustainability in mind, hence the illustration of a dance.

Striking this balance, and doing it quickly, will likely dictate the speed at which Malaysia will recover from this crisis and learn to live with the pandemic.

Coordinating this dance will require multi-agency collaboration that involves all of society.

Central to this thrust must be a change in testing strategy where testing must become a way of life. Population level testing with the adoption of rapid tests must be pursued.

Access to the tests, the procedure to carry out the tests and the contact tracing based on the reporting of the results must become second nature to the population at large.

The ecosystem supporting each of these processes must be built meticulously.

Testing ecosystem must be more than just an application, it must bring testing into every living room of the population.

Testing must be supported by robust contact tracing and disease control systems. The current public health apparatus was not built for long-lasting pandemics in large populations.

Innovation will be critical in upgrading these systems, but so will investments. Contact tracing in itself should be supported by proximity-based protocols and not just location-based protocols that can rapidly detect potentially high-risk contacts and quickly inform disease control teams. These applications must be built into a national disease control architecture that is integrated and intelligent.

Too many person hours have been wasted on redundant tasks that waste precious human resources unnecessarily.

Thresholds for action, the prescribed action and contingency plans can be built into the above architecture. These must include clear indicators that direct action.

This can include:

> Indicators of disease transmission such as the number of cases and deaths and its percentage change, the reproductive number, outbreak threshold based on seasonal patterns, and surveillance of excess mortality,

> Indicators of healthcare capacity such as the number of general or intensive care unit beds available, the number of healthcare workers infected with Covid-19 and the surge capacity limit, and

> Indicators of public health capacity such as number of cases with a source identified within a pre-defined time, a predefined proportion of contacts must be identified within a period of time and a proportion of that must be isolated and quarantined.

These are examples of clear indicators that can be utilised in tracking an endemic disease. These must be tied into a robust health information architecture that can support and integrate all the workflows effectively and seamlessly.

Vaccinations must also be aggressively pursued with the understanding that it is not a silver bullet. Covid-19 is here to stay with variants and waning immunity, further investments will be required to protect the population from death and disease via booster doses or next-generation vaccines.

Resuscitating the economy

The entire system must be tied in by a truly multidisciplinary team that would include individuals from all walks of life. Most importantly, the process should be transparent and with constant engagements with all levels of society.

In improving trust, data should also be democratised and made available for the population. Communication must be improved, and it can only improve if trust is earned.

The economy and the interlinkages to health can no longer be ignored. This framework of disease control proposed here must include a functioning economy.

Contingencies should be explored and the investments must be made in ensuring livelihood is preserved.

Despite being 611 days into a pandemic, it is clear that the end remains elusive. Every passing day, it becomes increasingly apparent that damaging lockdowns cannot be the long-term solution.

As vaccination rates surge, so must other efforts mentioned above as we prepare to enter the age of endemic Covid-19. Failing to do so will lead to another 611 days of infections, deaths, failures and tragedies.

Dr Dhesi Raja is the chief medical innovation officer of Ainqa and a public health medicine specialist. The views expressed here are the writer’s own.

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