Covid-19 was the worst public health disaster in Malaysia.
The first local case of this infectious disease was reported on Jan 25, 2020, and the second year of the pandemic was the worst.
According to the Health Ministry, a total of 2,840,225 cases have been reported as of Jan 25 (2022).
Last year (2021) on Jan 25, the total number of cases was 186,849.
This represents an increase in the total number of reported cases of 1,520%.
Meanwhile, the total number of reported deaths on Jan 25 (2022) was 31,918, compared to 689 a year before – an increase of 4,632.5%.
Malaysia has the highest number of reported cases and deaths per million population in Asean.
The issues in pandemic management include those with testing; contact-tracing; healthcare professionals; interaction with the private sector, universities and non- governmental organisations; associated illnesses (or co-morbidities); migrant workers; standard operating procedures; risk communication; political instability; and leadership.
At the beginning of this third year of the pandemic, it is time for a review and reset of our Covid-19 policy and strategies.
Adaptability and clear strategies
The SAR-CoV-2 virus has been very predictable with its unpredictability.
The duration of immunity to the virus, whether from vaccination or prior infection, is unknown.
Whether more transmissible, immune-evading or more virulent variants will follow the Omicron viral variant is unknown.
And whether Covid-19 will become a seasonal infection like influenza is unknown.
Some antiviral drugs have been ineffective against 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 their limitations.
Therefore, we need to acknowledge and accept that there is and will be a continuous need to adapt to an ever-changing situation, with speed of response being a critical factor in our effectiveness.
While modelling and predictions are necessary, they are evidence-based guesses based on the situation at that point in time and not mathematical certainties.
Public health, as well as economic and social functioning, in Malaysia requires both political and professional leadership to establish specific goals for Covid-19 management, benchmarks for public health measures, and reforms and investments in healthcare to prepare for future SARS-CoV-2 viral variants and/or pandemics.
We also need our leadership to have 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 Covid-19.
The tests available are the polymerase chain reaction (PCR) test and the antigen rapid test kit (RTK-Ag).
The PCR tests, which detect the genetic material of the SARS-CoV-2 virus, are the gold standard test.
The RTK-Ag tests detect proteins on the surface of the SARS-CoV-2 virus, and its results are more likely to be in line with positive PCR tests where the viral load is high.
Viral load is determined by the PCR test’s cycle threshold (CT) value, which is the number of amplification cycles needed to produce sufficient viral RNA (ribonucleic acid) for detection.
The lower the CT value, the higher the viral load, and the more severe the infection.
However, many PCR results are presented as positive or negative, without CT values.
The Health Ministry reported a total of 181,238 tests, which comprised 87,780 PCR and 93,458 RTK-Ag tests, on Aug 12, 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%) PCR tests and 570,073 (51.97%) RTK-Ag tests.
The daily average was 75,280 PCR tests and 81,439 RTK-Ag tests.
The highest number of PCR tests done, i.e. 90,293 tests, was reported on Aug 19, 2021.
Delays in diagnostic testing have a domino effect on contact-tracing and disease spread, 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.
Is Malaysia’s testing capacity sufficient for the current Omicron surge?
There is a view that screening for asymptomatic disease is no longer necessary.
How then will this impact on the spread of the disease and public health management?
The Medical Device Authority (MDA) has given conditional approval to 124 self-test kits.
However, there is no public data available on the kits’ user acceptability, their real-world reliability and the sales numbers.
Surely the public who purchase these kits, with many paying out-of-pocket, have a right to information about their reliability.
Malaysia needs a comprehensive testing and reporting system, which should accommodate the incorporation of home tests, 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.
This is 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, predominantly manual methods of contact-tracing have to give way to digital techniques, particularly since the current case numbers are so large.
It is a shame that the gene-sequencing capacity of Malaysia lags behind that of less developed Asean countries like Cambodia.
We have to beef up our gene-sequencing capacity for it to be useful in decision-making.
Surveillance
The Omicron viral variant has emphasised the need for comprehensive and nationwide surveillance, which should include environmental surveillance like wastewater.
Traditional surveillance is usually reactive, which means that it is usually too late to contain the spread of an emergent viral variant.
A comprehensive national system should be capable of empowering state and 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 viral variants and any immunity escape.
This requires 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, e.g. differences in socio-demographics, public attitudes, vaccines used, etc.
Non-pharmaceutical interventions
The SARS-CoV-2 virus is spread mainly by aerosols, and sometimes, respiratory droplets (the difference lies in their size, with aerosols being smaller).
Non-pharmaceutical interventions (NPI) continue to have an important role in limiting the spread of the virus, as multiple measures, apart from vaccination, are needed to limit its rate of spread.
Omicron spreads very easily with a doubling time of 1.5 to three days, compared to the six to eight days of the Delta variant.
Many countries are encouraging the 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 upgraded ventilation and air filtration systems, including the use of outside air, efficient filters (minimum efficiency reporting value, MERV, of 13 or more) and high-efficiency particulate air (HEPA) filtering devices.
HEPA filters are more that 99.97% efficient at capturing airborne viral particles associated with SARS-CoV-2.
Such ventilation systems need to be installed 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 Occupational Safety and Health Department and the Human Resource Ministry last July and August (2021).
However, we have yet to hear about implementation, monitoring and compliance.
*Watch out for the second part of this article in print on March 13 (2022) and online on March 15 (2022).
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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