Will the conditional MCO be enough to control the spread of Covid-19?

Workers cleaning and disinfecting tables and chairs at a Penang hawker shop in preparation for reopening under the conditional MCO. Although not mentioned in the SOP for the conditional MCO, commonly-touched surfaces should to be cleaned and disinfected regularly to prevent Covid-19 infection. — CHAN BOON KAI/The Star

The Prime Minister announced on May 1 (2020) that almost all economic sectors and activities will be permitted to operate, subject to conditions and standard operating procedures (SOPs).

However, some businesses and activities will not be permitted, which are listed on the National Security Council’s website.

The SARS-CoV-2 virus that causes Covid-19 does not respect humans, let alone the Government’s decision to relax the movement control order (MCO).

As such, it is vital that all measures to prevent spread of the infection are adhered to at all times and without exception.

Measures to follow

The Government announced four new norms in its document, SOP Pembukaan Semula Ekonomi (May 1 version): health measures, personal hygiene, control of spread and avoidance of group gatherings.

The health measures in the SOP are social distancing of at least 1m ‑ and preferably 2m in all situations ‑ and the use of face masks.

Social distancing is possible if offices have large areas with small numbers of staff.

In those with smaller areas or large numbers of staff, changes like staggered working hours, working in the office on alternate days or working from home, would have to be considered.

The use of face masks is limited by access, availability, cost and effectiveness.

The degree of prevention of infection spread by face masks is variable.

In addition, there are quality issues with some face masks.

More importantly, large scale usage of masks by the public would affect the numbers available to healthcare staff and other frontliners.

Personal hygiene measures in the SOP are handwashing with soap and water, or alternatively, use of a hand sanitiser, as well as making these measures available to staff and visitors; and sanitising business premises at least twice daily.

The SOP should have also stated that:

  • Handwashing with soap and water should be frequent and of 40-60 seconds duration (the length of the Happy Birthday song sung twice).
  • Only alcohol-based (at least 60% alcohol content) hand sanitisers are effective.
  • The eyes, face and nose should not be touched by the hands until after the hands have been cleansed.
  • When coughing or sneezing, the mouth and/or nose should be covered with tissue or bent elbow, and the tissue should be disposed of and the hands washed with soap and water or cleansed with alcohol-based (>60%) hand sanitiser immediately.
  • Frequently used items like door knobs, lift buttons, hand rails etc should be avoided and/or disinfected according to frequency of usage. This will have to be more than twice daily when there is much usage.
  • Anyone who has a fever, dry cough, sore throat, headache, breathing problems, blueish lips or face, diarrhoea, loss of smell and/or taste, fatigue or is unwell should seek immediate medical attention.

Infection control measures in the SOP include protocol for surveillance and control; daily screening of all employees for Covid-19 symptoms and body temperature; use of appropriate personal protective equipment (PPE) where social distancing is not possible; reporting to the Health Department if there are new cases of Covid-19; and educating employees in monitoring and action to be taken in suspected cases of Covid-19.

Detailed guidance from the Health Ministry would be necessary for businesses to have a protocol for surveillance and control.

Daily screening of all employees would incur additional time and effort, particularly with large numbers.

This could be addressed with specific times for entry into premises, variable work hours etc.

The use of face masks where social distancing is not possible would be problematic as mentioned above.

As the diagnosis and monitoring of Covid-19 is clinical, it would be difficult for laypersons to report suspected cases.

The effectiveness of educating employees about Covid-19 is dependent on the individual’s health literacy.

The avoidance of gatherings in groups is the fourth norm in the SOP.

The rationale for the numbers should be made known. In some countries, the number of people allowed to gather are in single digits.

Regrettably, the SOP did not emphasise that everyone should consider all their contacts as potentially Covid-19 positive.

This would promote strict adherence to the health, personal hygiene and infection control measures in the SOP.

Employees are advised to wear face masks to avoid the spread of the SARS-CoV-2 virus; however, its use is limited by access, availability, cost and effectiveness. — BernamaEmployees are advised to wear face masks to avoid the spread of the SARS-CoV-2 virus; however, its use is limited by access, availability, cost and effectiveness. — Bernama

Questions and considerations

It was announced on April 23 (2020) that the MCO was extended to May 12 (2020).

Yet many of the restrictions were abruptly lifted about a week later, leaving little or no time for employers to prepare to comply with the SOPs.

What was the rationale behind this?

That economic considerations were the primary factor in the latest decision was reflected in the disclosure that the drop in exports for the manufacturing sector alone was estimated at RM32bil for every two weeks of the MCO.

Were public health considerations factored in the decision? It appeared not.

The new positives in the second half of April (2020) were in double digits, compared to triple digits in the first half of the month, so much so that the Health Ministry expressed confidence that it could be in single digits in mid-May (2020).

Was this a factor in the decision-making?

Yet the new positives went back to triple digits on May 2 and 3 (2020), demonstrating the illusion of daily numbers when the focus should be on trends.

The primary reason is that Malaysia’s testing numbers are relatively less, compared to our neighbours (see graphic).

Malaysia has testing capacity limitations, i.e. test laboratories and kits, so it has targeted screening on case clusters, where diagnosis rates were less than 1%, giving rise to the belief that there is no necessity to waste limited resources.

However, it is generally accepted that the more tests done, the better the numbers reflect the actual cases in the community.

Experts increasingly believe that asymptomatic patients (those without any symptoms) are an important source of spread.

The Selangor Menteri Besar reported that four out of five positives (80%) in 649 samples in Hulu Langat were asymptomatic.

What is the prevalence of asymptomatics in the population?

Is the Health Ministry’s daily report reflective of the actual reality on the ground?

Did the spike of imported cases on April 29 influence the decision?

That there is continuing local spread is obvious from the daily reported numbers.

Phased lifting of the MCO, continued testing and contract tracing, border control, monitoring, review and population seroprevalence studies were recommended by a former Health deputy director-general.

Were these rational recommendations considered?

There were three pandemic waves in the 1918 influenza pandemic. Will this also occur with the Covid-19 pandemic?

Social distancing still needs to be practised under the conditional MCO. — AZHAR MAHFOF/The StarSocial distancing still needs to be practised under the conditional MCO. — AZHAR MAHFOF/The Star

Health first

Balancing lives and livelihoods were stated in the public messages.

It is vital that those focusing on economic considerations remember that without lives, livelihoods are irrelevant.

The Covid-19 pandemic is not going away for at least the next 18-24 months when a vaccine(s) becomes available or there is sufficient herd immunity (at least 60%-70% of the population have been infected and recovered).

Until then, it is advisable for everyone to adhere strictly to frequent handwashing or use 60% or more alcohol-based hand sanitisers; avoiding touching the face, nose and mouth; cough and sneezing etiquette; social distancing; avoiding crowds; staying at home when unwell; seeking early medical attention when ill; and keeping up-to-date with information from reliable sources.

It is also advisable that public health, and not just economics, be a major factor in policy decisions.

Dr Milton Lum is a past president of the Federation of Private Medical Practitioners Associations and the Malaysian Medical Association. For more information, email starhealth@thestar.com.my. The views expressed do not represent that of organisa-tions that the writer is associated with. The information provided is for educational and communication purposes only and it should not be construed as personal medical advice. Information published in this article is not intended to replace, supplant or augment a consultation with a health professional regarding the reader’s own medical care. The Star disclaims all responsibility for any losses, damage to property or personal injury suffered directly or indirectly from reliance on such information.

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