Living with endemic Covid-19

With most future Covid-19 patients expected to be able to quarantine at home, telemedicine has a potentially large role to play and needs to be more tightly regulated for patient privacy and safety. — 123rf.com

After over two years of living with strict emergency measures to curb Covid-19, Malaysia now joins the global movement to transition from pandemic status to endemicity.

While the duration of this transition phase is yet to be defined, the SARS-CoV-2 virus is expected to be present among the Malaysian population indefinitely.

The ideal scenario is to completely eradicate the virus through a combination of luck, public health measures, vaccines and anti-viral medicines, but two years of battling Covid-19 has proved that this ideal scenario is impossible.

Indeed, there is a difference between eradication and elimination of infectious diseases.

Eradication means a “permanent reduction to zero cases worldwide”.

So far, throughout known medical history, only smallpox has been eradicated.

Elimination means “reduction to zero cases in a defined geographical area”, like countries or states.

Humanity has had better luck with elimination, for example, eliminating polio or neonatal tetanus in many regions of the world.

Endemicity means “a constant rate of cases of a particular infectious disease”.

There is no clear epidemiological or scientific cut-off point between pandemic and endemic.

The world will not wake up one day and declare that Covid-19 is “pandemic today, and endemic tomorrow”.

Therefore, it is possible and helpful to compare Covid-19 to dengue fever, another endemic disease with some characteristics similar to Covid-19.

Dengue is caused by a virus with an approximately similar period of illness and treated mostly symptomatically.

It has been reported in Malaysia for at least the past 120 years.

As dengue is transmitted via the Aedes mosquito, we prevent the disease by preventing contact with the mosquitoes through the use of mosquito nets, mosquito repellents and fogging (to kill the mosquitoes).

In parallel, physical distancing and movement restrictions help to prevent the transmission of Covid-19.

However, just as it is not possible to completely destroy Aedes mosquitoes, prolonged enforcement of stringent standard operating procedures (SOPs) for Covid-19 has taken a toll on Malaysians.

In contrast to dengue, we have safe and effective vaccines for Covid-19 and some effective anti- viral drugs.

As of this month, CovidNow data shows that about 80% of the Malaysian population have received at least two doses of a Covid-19 vaccine.

This progress is in line with the goal to achieve herd immunity, where the chain of infection is broken by interspersing vulnerable groups with a larger number of the immune population.

However, even if 100% of our population are vaccinated, Covid-19 will likely persist.

This is because of the biological nature of the coronavirus, which has the ability to mutate, and thus evade the immunity provided by vaccination.

In other words, vaccination does reduce the severity and infectivity of Covid-19, but any slight mutation of the virus could render even a vaccinated person susceptible to being infected.

This is evidenced by the infections, and even deaths, among the vaccinated, as well as re-infection of those who have recovered from the disease.

What other countries are doing

Mongolia was the fastest country in the world to relax its Covid-19 restrictions, including fully opening its borders to travellers, without requiring pre-arrival Covid-19 tests or post-arrival quarantine. — AFP

Globally, with the gradual relaxation of restrictions, many countries are moving to treat Covid-19 as endemic.

For example, Singapore made face mask-wearing optional in outdoor settings from March 29 (2022), and fully-vaccinated individuals travelling to Indonesia no longer need to be quarantined.

At the moment, however, no country has yet to declare Covid-19 endemic, mostly because this is a political statement, as much as it is a scientific and mathematical one.

As of this month (April 2022), the Covid-19 Stringency Index, developed by Oxford University in the United Kingdom, ranks Malaysia above 140th place, while Mongolia, the UK and Portugal are among the least strict countries in governmental responses to the pandemic.

The national measures that form the index include school closures, travel restrictions, public gatherings and financial investment in the health systems responsible for contact tracing and vaccination.

Ranking first in the list is Mongolia, the fastest country to relax.

Among its back-to-normal routines are the reopening of schools and workplaces, and full opening of international borders with no required pre-arrival Covid-19 test or post-arrival quarantine.

Since last month (March 2022), the daily number of cases in Mongolia has plateaued below 1,000, and deaths per day have not exceeded four daily since last December (2019).

The country has achieved a 92% full vaccination rate, while restrictions due to Covid-19 have been lowered to almost pre-Covid levels as of last month (March 2022).

For the UK, unvaccinated individuals travelling there do not need to test for Covid-19 pre-departure or post-arrival.

In Scotland, face masks are no longer required in outdoor areas.

In Wales and England, face masks are not required in closed areas, except in health and social care settings.

The legal requirement for people to self-isolate if they have Covid-19 has also ended.

According to the Our World in Data website, the UK was still in the range of 60,000-80,000 cases daily last month (March 2022), but the case fatality rate (number of deaths divided by the number of cases) has been below 1% since the beginning of the year (2022).

As of March 31 (2022), 72.5% of the British population have completed their vaccination protocol.

Two possible reasons why the UK is able to lift most of its restrictions, even with a relatively low vaccination rate, is their advanced healthcare facilities and universal health coverage through their National Health Service.

While the case fatality rates for both Malaysia and the UK are similar in the range of 0.7-0.9%, the total number of cases in the UK is about five times that of Malaysia.

Hence, with our healthcare facilities, Malaysia is moving at a reasonable pace towards endemicity, as we cannot move as fast as other countries.

What else can we do?

Like the influenza virus, annual genomic surveillance of the SARS-CoV-2 virus might be necessary to keep track of which strain or variant is predominantly infecting people every year. — AP

Once the number of cases plateaus in Malaysia, further steps in the transition to Covid-19 endemicity should be considered.

There are three important areas to focus on besides vaccinations and boosters.

First, as the restrictions are being loosened gradually, we should anticipate a rise in category 1 and 2 cases among the large proportion of the population that has been vaccinated.

Since most of these patients can be quarantined at home, telemedicine will play an important role in healthcare provision, which will also prevent healthcare personnel from being exposed to unnecessary risk.

As of now, the field of digital healthcare in Malaysia is fast-growing, but lightly-regulated.

In order to accommodate the expected uptrend in the number of cases, telemedicine can increase healthcare capacity without the associated cost of procuring physical buildings and beds, as long as appropriate regulations protect patient safety.

Secondly, as the number of cases rise, there will likely be a rise in people affected with long Covid.

This sequela of Covid-19 adversely affects quality of life and is not dependent on the severity of the initial Covid-19 infection (according to the US Centres for Disease Control and Prevention last September [2019]).

Currently in Malaysia, rehabilitation services are mostly provided to patients recovering from severe Covid-19 (categories 4 and 5), while milder cases are not seeing any doctor.

Closing this gap will minimise the effect on economic productivity and reduce long-term effects on physical and mental health.

Thirdly, in view of the mutative character of the SARS-CoV-2 virus, there should be at least a yearly surveillance of the strain of coronavirus dominantly infecting the population.

This data can guide appropriate booster vaccine doses, from research to production and booster policies.

Without allocating genomic surveillance resources ahead of time, we may repeat the history of the Delta and Omicron viral variants.

During the transition to an endemic Covid-19, the number of cases is expected to peak and fall for some time.

Scientists still do not know how long Covid-19 will last, but we can learn lessons from the speed of reopening by other countries, and from other endemic diseases like dengue.

Dr Khor Swee Kheng is a physician specialising in health policies and global health. He tweets as @DrKhorSK. Dr Ginsky Chan is a medical officer now pursuing a Masters in Public Health at the London School of Hygiene & Tropical Medicine. The views expressed here are entirely their own. For more information, email [e-mail]. The information provided is for educational and communication purposes only. The Star does not give any warranty on accuracy, completeness, functionality, usefulness or other assurances as to the content appearing in this column. The Star disclaims all responsibility for any losses, damage to property or personal injury suffered directly or indirectly from reliance on such information.