Will there be a Covid-19 surge with restrictions lifted?

An important question when considering vaccination coverage in Malaysia is whether all migrant workers, both documented and undocumented, are being included in the population count. — S.S.KANESAN/The Star

The Klang Valley and Melaka moved into phase 4 of the National Recovery Plan (NRP) on Oct 18 (2021), with the rest of Peninsular Malaysia in phase 3 of the NRP.

In short, this means that there will be more movements and interactions by and between people.

Covid-19 was the worst public health disaster in Malaysia.

As of Oct 17 (2021), there were almost 2.4 million infected individuals, with almost 28,000 confirmed deaths.

In the global league of cumulative reported cases, Malaysia ranked 20th on Sept 25 (2021), compared to 85th on Nov 18, 2020.

Malaysia’s cumulative confirmed reported cases and deaths per million population were the highest in Asia.

The question that many are asking is whether there will be another Covid-19 surge with the move to NRP phases 3 and 4 in Peninsular Malaysia.

There are reasons for both optimism and pessimism.

The good news

Whether or not Covid-19 cases will rise after the lifting of current restrictions will depend on luck and individual efforts in continuing preventive behaviours like physical distancing. — YAP CHEE HONG/The StarWhether or not Covid-19 cases will rise after the lifting of current restrictions will depend on luck and individual efforts in continuing preventive behaviours like physical distancing. — YAP CHEE HONG/The Star

The bright spot in Malaysia’s Covid-19 management is the vaccination effort, with 22.8 million (69.7%) of the population fully vaccinated and 25.2 million (77.2%) having had one vaccine dose as of Oct 17 (2021).

The vaccination numbers are the primary reason for optimism in the months ahead.

Some of the unvaccinated have natural immunity from the infection itself, having recovered from the disease.

However, their numbers have not been disclosed as many of the infected were also vaccinated.

More vaccinations should provide optimism.

Other factors like adherence to non-pharmaceutical interventions, testing and contact-tracing rates, will also play significant roles.

Trial data on Covid-19 vaccination for children as young as five to 11 years are expected in this quarter of the year (2021).

If these vaccines prove effective and safe for this group of children, then authorisation of their usage would increase vaccination rates further.

Meanwhile, booster shots will address waning immunity in senior citizens, the immunocompromised and those who have increased occupational exposure to the SARS-CoV-2 virus.

At some point in time, the virus will start to run out of unprotected people to infect.

Although there are breakthrough infections among the vaccinated, they are significantly less likely to develop severe and critical disease, compared to the unvaccinated.

The more people with immunity – whether from vaccination or infection – the less likely Covid-19 will spread, with corresponding fewer deaths.

According to Health Ministry data, the positive cases and death numbers are falling.

Whether it will continue on its downward trend is the million-dollar question, particularly as modelling is fraught with uncertainty because of variables, some of which are unforeseen.

For example, the effects of vaccine mandates or privileges for the vaccinated are unknown.

How Malaysia will end up will probably depend on luck (i.e. if the SARS-CoV-2 virus does not become more virulent or transmissible) and on individual behaviour (i.e. decisions on whether to get vaccinated, which will reduce the likelihood of new variants, and strict compliance with standard opera-ting procedures).

It is likely that the situations in different states will vary.

Covid-19 will likely remain endemic and still cause suffering.

However, if there is resumption of some aspects of pre-pandemic life and the healthcare delivery system has a chance to recover and prepare for the next emergency, it will be an enormous step.

The bad news

One concern is if we are doing sufficient testing and contact-tracing to detect and prevent cases of Covid-19. — FilepicOne concern is if we are doing sufficient testing and contact-tracing to detect and prevent cases of Covid-19. — Filepic

But in the same Health Ministry data, there are also reasons for pessimism.

The SARS-CoV-2 virus has fooled humanity before and can do so again.

The Delta variant has now become predominant globally, eclipsing the Alpha, Beta and Gamma variants.

With continuing widespread community spread, the likelihood of new, more virulent and transmissible variants emerging is high.

High vaccination rates are no match for the Delta variant.

The resurgence of infections in countries with high vaccination rates, e.g. Israel and Singapore, provide salutary lessons.

Of relevance is whether the estimated 32.7 million population from the Statistics Department includes migrant workers, and what proportion of migrant workers – particularly the undocumented – have been vaccinated.

According to the ministry’s data, as of Oct 17 (2021), the unvaccinated comprised 22.8% of the population, i.e. about 7.9 million people.

Does this number include migrant workers?

Daily vaccination rates have decreased dramatically with the closure of many vaccination centres.

Punitive action against the small, but vocal, anti-vaccine community may have the unintended effect of increasing vaccine hesitancy.

This is particularly so with parents who have concerns about the administration of a new vaccine to their children.

These concerns are not unique to the Covid-19 vaccine, e.g. it took years for vaccination rates for measles, poliomyelitis, chicken pox and other childhood infections to reach 90% or more in many countries.

The answer to the anti-vaccine community’s propaganda has to be public education.

Unfortunately, the Health Ministry’s efforts are nothing to shout about, with the content and language of its public health messages leaving much to be desired.

Although the ministry has reported low health literacy in Malaysia, its messages are only in Bahasa Malaysia and English, not even Bahasa Iban, Bahasa Kadazan, Chinese, Tamil, or the common languages of migrant workers in Malaysia like Bengali, Nepali and Burmese.

The public’s response to the exhortations to continue to adhere to SOPs on non-pharmaceutical interventions like physical distancing and face mask-wearing, as the country moves into phases 3 and 4 of the NRP, is a significant unknown.

There has been insufficient testing for Covid-19, and by extension, contact-tracing.

The World Health Organization (WHO) positivity rate for sufficient testing is 5% or less.

Since mid-May (2021), the positivity rates have exceeded this number, with a downward trend in the past month.

The trend is important, and not the positivity rates of 5% or less on isolated days.

Furthermore, the Health Ministry has not disclosed its compliance with WHO’s benchmark for successful contact-tracing, i.e. to trace and quarantine 80% of close contacts within three days of confirmation of a case.

The WHO recommended six criteria when considering the lifting of restrictions:

  • Controlled transmission
  • Capacity of the health system in place to detect, test, isolate and treat every case and trace every contact
  • Outbreak risks minimised in special settings like health facilities and nursing homes
  • Preventive measures in place in workplaces, schools and other places where it’s essential for people to go
  • Manageable importation risks, and
  • Fully-educated, engaged and empowered communities adjusted to the “new norm”.

Was the decision to move into NRP phases 3 and 4 in accordance with the WHO’s recommendations?

We haven’t won yet

The jury is still out on the impact of opening up of Malaysia on Covid-19.

However, in view of the aforesaid, another surge of Covid-19 is probable.

How the healthcare system will cope is another pertinent question.

We cannot claim victory over Covid-19 as the SARS-CoV-2 virus is not going anywhere yet.

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 organisations 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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