The number of reported Covid-19 cases exceeded four million on March 21 (2022). Malaysia continues to have the highest number of Covid-19 deaths per capita in Asean.
The predominant SARS-CoV-2 viral variant continues to be the Omicron variant, taking over from the previously dominant Delta variant.
With this infectious disease’s unpredictability continuing, a reset of policy and strategies is imperative.
Some areas, like a need for adaptability and clear strategies, testing and tracing, surveillance, and non-pharmaceutical interventions, have been covered in a previous column.
This column sets out further areas in need of a reset of policies and strategies.
Covid-19 vaccines have significantly reduced severe disease, hospitalisations and deaths.
Preliminary findings show that mRNA-based (messenger ribonucleic acid) vaccine boosters are more effective against the Omicron variant, compared to the primary series of mRNA, viral-vectored, protein and inactivated vaccines alone, although there are unanswered questions about the sustainability of the immunity conferred.
Natural immunity from prior SARS-CoV-2 infection is insufficient against a new infection by the Omicron variant, but may protect against severe disease and death.
It is important to remember that each individual’s immunological responses can be different from others.
There are still unanswered questions about Covid-19 vaccines, e.g.:
- What is the optimal dosing interval?
- What is the optimal combination and schedule?
- Is there an effective prime/booster regimen when combining vaccines?
Will we be able to obtain these answers from local scientists through focused research?
Or would Malaysia have to extrapolate from such studies in other countries?
There are several effective therapeutics for Covid-19, e.g. remdesivir, dexamethasone and monoclonal antibodies, which were tested against earlier viral variants, including the Delta variant.
However, all but one of the monoclonal antibodies are ineffective against the Omicron variant, requiring their redesign.
Reports of the availability of oral antivirals like molnupiravir and the combination of nirmatrelvir and ritonavir have raised hope and expectations.
However, unresolved issues with these medicines include:
- Severely limited supply, even in developed countries
- Inadequate coordination between testing and treatment
- Monitoring for emergence of virus strains resistant to treatment, and
- Pre- and post-exposure prophylaxis.
Malaysia implemented its Covid-19 vaccination programme months after other countries in the Asia-Pacific did.
Hopefully, the lessons from the delay would not have been lost.
The need for continuous attention, monitoring and action on next-generation Covid-19 vaccines and therapeutics has to be reiterated.
In addition, improvements in the regulatory processes are needed.
The concerns of the vaccine-hesitant have to be addressed, with more needing to be done.
Vaccine mandates continue to be a contentious issue globally.
Decisions have to be made about whether to have vaccine mandates, and if so, the circumstances in which they are applicable.
The public and healthcare professionals need communication from the authorities who should let their experts talk about updates, goals and plans.
Similarly, communication from the ground is needed.
Questions from the public and healthcare professionals need answers, but more importantly, policymakers need to hear the perspectives from the ground.
While there will not always be agreement, the authorities need to listen to the frontliners.
Listening is different from hearing as it requires effort that is active, intentional and focused.
Risk communication by the authorities since the Covid-19 pandemic began, left much to be desired until the current Health Minister took office late last August (2021).
Since then, there have been improvements in the quality of ministerial statements.
However, those involved in making public announcements should take heed, internalise and emulate the principles and vignettes stated in the World Health Organization’s (WHO’s) January 2018 document titled Communicating risk in public health emergencies.
Covid-19 exposed Malaysia’s public health chasms.
There were, among others, limited personnel, imprecise data on disease spread, very limited genomic surveillance, imprecise projections and the use of possibly non-generalisable data from other countries.
Delays in recognising that Covid-19 was a public health problem was reflected in the clinical response in the pandemic’s first year, which contributed to the disastrous numbers in the second year.
The whole-of-society collaborative concept was spewed ad nauseam in the first year of the pandemic.
The method of implementation and non-compliance to non-pharmaceutical interventions (NPI) measures and the behaviours of some politicians undermined public trust.
Going forward, in order to respond to future outbreaks, there is need for real-time information systems, a rejuvenated public health workforce, flexibility and public trust, with the implementation of measures founded on the belief in the value of collective action for the public good.
An integrated digital information system includes real-time electronic information on respiratory viral infections (including Covid-19), hospitalisations, deaths, disease-specific outcomes and vaccinations, which incorporate socio-demographic and other relevant data.
The system should include data from all healthcare facilities, as well as environmental and genomic surveillance, to facilitate tracking of outbreaks and target containment.
The public health workforce needs to be strengthened considerably with inclusion of personnel from non-traditional sources like non-governmental organisations (NGOs).
The latter could be trained in the administration of testing, vaccination, adherence to ongoing treatment for common infectious and non-communicable diseases, and delivery of other public health services to the vulnerable and homebound.
Strengthening of school health services to meet unmet public health needs, would necessitate adequate funding and staffing.
Measures that improve ethnic diversity and cultural competence of the healthcare workforce will help to alleviate disparities; improve outcomes and rebuild public trust more widely.
The government announced on Oct 18, 2021, that the then 181 standard operating procedures had been condensed into one SOP with nine guidelines, which was awaiting approval.
A subsequent announcement confirming the approval was made on March 9.
While there is removal of restrictions, the question of what is an acceptable national/state risk level has not been disclosed.
The goal has to be “living with Covid”. The eradication or elimination – i.e. “zero Covid” – strategy adopted by China is not a practical possibility.
Infectious diseases cannot be eliminated when there is limited lifelong immunity following infection, vaccination or non-human infection reservoirs.
The majority of Covid-19 infections are asymptomatic or mildly symptomatic. Its short incubation period precludes targeted strategies. It does not seem like there is lifelong immunity to Covid-19 following vaccination or infection.
Current vaccines prevent severe disease and hospitalisation. However, breakthrough infections can occur even after completion of the current vaccination schedule.
Endemicity, like herd immunity, has been one of the most misused terms during the pandemic.
Endemicity is the “new normal”.
This means that Covid-19 has to be accepted as an infection that is always present in the population, just like all other respiratory viral infections, e.g. the common cold, influenza, respiratory syncytial virus (RSV), etc.
Endemicity does not equate with no cases, or that Covid-19 is harmless.
It means that Covid-19 will be just like dengue and malaria, which are endemic in Malaysia, with cases occurring all the time and sometimes spiking higher, but whose numbers do not usually overwhelm the healthcare system.
The public have been able to live with these infections, although more can be done to reduce their individual and collective risks.
This was well-summarised by Oxford University evolutionary virologist Prof Aris Katzourakis in a commentary published in the science journal Nature: “Stating that an infection will become endemic says nothing about how long it might take to reach stasis, what the case rates, morbidity levels or death rates will be, or crucially, how much of a population – and which sectors – will be susceptible.
“Nor does it suggest guaranteed stability: there can still be disruptive waves from endemic infections, as seen with the US measles outbreak in 2019.
“Health policies and individual behaviour will determine what form – out of many possibilities – endemic Covid-19 takes...
“Thinking that endemicity is both mild and inevitable is more than wrong, it is dangerous: it sets humanity up for many more years of disease, including unpredictable waves of outbreaks.
“It is more productive to consider how bad things could get if we keep giving the virus opportunities to outwit us.
“Then we might do more to ensure that this does not happen.”
An informed decision has to be made on what is an acceptable national/state risk level of viral respiratory diseases, including SARS-CoV-2.
This level should reflect the viral level within the community, hospitalisations, deaths, hospital bed capacity and healthcare workforce capacity, to enable national/state levels decisions on planning and the timing of emergency mitigation measures.
Malaysia is still not in an endemic state.
Viral spread has not stabilised with swings still occurring nationally and in certain states.
Societal disruptions have not disappeared.
When Malaysia reaches an endemic state, the virus will not make an announcement, although some politicians may try.
Endemicity will happen gradually and no one will know until it has passed.
Despite the Covid-19 pandemic, there has been no concerted attempt to institute necessary reforms to address the healthcare system’s defects.
Without a strategic plan for the “new normal” with endemic Covid-19, there will be unnecessary ill-ness and death, widening health inequities and substantial economic loss.
The resources needed to build and sustain an effective health infrastructure will be substantial.
Policymakers should not only consider the costs, but also the benefits, including less illness, fewer deaths and recovery of lost productivity due to the pandemic, all other infections and non-communicable diseases.
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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