ALMOST a week has passed since we rolled back a significant portion of our Covid-19 countermeasures.
Looking at photos on social media of people celebrating the festive season with friends and family, there is a distinct return to near normalcy. And while we should rejoice at these innate freedoms that were curtailed for two years because of the pandemic, we should also take stock of some key lessons and cast an eye on what might be next in living with this virus.
We need to accept that there will be waves of infection. Numbers will go up and down with spikes and troughs that will be associated with waning immunity, new variants, population interaction (during festivities), and seasonal factors.
In confronting these waves, we will continue to apply our four-pronged strategy that has brought us safely to the present “transition to endemic” phase: save lives, reduce the severity of the disease (especially to high-risk groups), protect the public healthcare system, and facilitate the recovery of livelihoods.
Take our recent experience with the Omicron wave. We were in a good place towards the end of last year. Case numbers and severity metrics (deaths and ICU usage) were back to pre-Delta levels.
Then we heard about the new variant. We knew it spread fast. But we did not know the severity of the disease it would cause. We decided on a combination of countermeasures. There was some tightening of border controls to delay the wave from hitting us too fast. We reactivated the rapid response task force to ensure that there would be enough critical care beds for a surge capacity scenario.
And we aggressively promoted our booster shots, especially for the elderly and those who took the inactivated vaccine for their primary series to top up with an mRNA booster.
Our response, combined with what we now know of Omicron’s lower severity compared to Delta, meant that although cases during peak Omicron were 35% higher than peak Delta, key severity metrics were 70% lower.
As we understood better the Omicron “decoupling” of case numbers (high) from severity (low), I was able to make a judgment call in March that it was time to ease restrictions to facilitate the recovery of livelihoods.
After the Quartet of Ministers deliberated, we presented the transition to endemic plan to the Prime Minister and it was announced effective April 1, and this was followed by the recent set of SOP (standard operating procedure) changes effective May.
We decided on a step wise and calibrated approach. There was not going to be just one “freedom day”, but rather a sequenced set of relaxations and signalling that would be prudent for public health, facilitate economic recovery, and align with the behavioural choices of the majority of Malaysians.
For instance, unlike some countries that have decided to completely abandon the mask mandate whether indoor or in open spaces, we decided to keep our masks on indoors and recommend them in crowded outdoor spaces. We feel this follows the science of indoor contagion risk but also, crucially, what most Malaysians would be comfortable with.
That’s why you still see many happily wearing masks outdoors. Public health choices should align with societal behaviour and expectations. It is probably different in some countries where masks are seen as an infringement on their right to live free or die. You do you.
The other reason for the continuation of masks indoor is related to a bigger concern – protecting the vulnerable.
Although Malaysia has among the best Covid-19 vaccination coverage in the world, there remain groups who are still considered high risk. These include the elderly, the unvaccinated (including young children), those with serious comorbidities and people who are immunocompromised.
With our high vaccination coverage, more than 95% of active cases now just isolate and recuperate at home. Covid-19, new variants notwithstanding, is becoming a bad case of flu for people who are otherwise healthy and vaccinated.
But for the vulnerable, the virus can still be deadly. So apart from masks that can help protect them, we also need to ensure that vulnerable groups are prioritised when it comes to anti-viral treatments, good clinical care pathways at our hospitals, home recovery monitoring and additional boosters.
What can we expect when it comes to additional boosters for everyone else? We know that humoral immunity from both vaccination and infection wanes over time. We are now beginning to understand more about the longevity of cellular immunity and that will also impact future decisions on boosters.
Although Covid-19 vaccinations were never legally mandatory in Malaysia, we aggressively pushed the immunisation campaign, including denying those who were unvaccinated from entering certain premises.
Now with 98% of adults fully vaccinated and half the population boosted, subsequent doses will be recommended to certain groups who can then decide if they want a further top-up jab. This will be consistent with personal responsibility in the transition-to-endemic phase, which will depend on people doing individual risk assessments on what they want to do and how they want to live their lives.
The other thing to note about vaccines is the need to keep updated with data from trials that will continue to take place on pan corona vaccines that can protect us against known and unknown variants, offer long-lasting immunity of years, not months, and crucially, provide sterilising immunity, which means it helps reduce transmission and not just the severity of disease. If such a vaccine can be developed, it may be worth doing another round of mass immunisation.
Finally, as testing numbers decrease, we need to think about how best to continue surveillance both for the prevalence of cases as well as for variants. As testing continues to shift away from lab-based PCR assays to lateral flow RTK home kits, it becomes even more important for us to report our self-tests via MySejahtera.
I am aware there is pandemic fatigue, but by not reporting, you are contributing to a blind spot for virus detection in the community. And while the Health Ministry continues with sentinel testing at our clinics and looks to expand other methods like wastewater analysis, data from self-tests are extremely useful.
We know people are also reluctant to report a positive result because they do not want a seven-day HSO (Home Surveillance Order) notice.
That’s why you can now test-to-release if negative on day four.
In any case, successfully transitioning to endemicity means everyone still playing their part and being truthful about their health status – this is community solidarity. Don’t be selfish.
On surveillance for new variants, one big challenge now is resources. After having spent so much money on the pandemic, getting continued financial allocation to conduct expensive whole genomic sequencing (WGS) to detect which variant or sub-lineage is spreading in Malaysia will be tough, but extremely necessary.
Without a decent number of WGS, we will not know quickly enough the trajectory of the disease and how to respond to it. We have been lucky that Omicron is not as severe as Delta in Malaysia.
The doomsday scenario will, of course, be a deltacron variant – highly transmissible and virulent. And with large swathes of the world population still unvaccinated and the virus still circulating globally, mutations will happen and we need to stay ahead of this.
As we continue to celebrate during the month of Syawal, don’t be alarmed if case numbers go up. This is part of us living with waves of cases that I mentioned above until eventually we reach some endemic point in the future. As long as the severity of these cases is low and our hospital capacity is protected (not just for Covid-19, but to clear massive backlogs from the last two years), we can continue to safely transition to endemicity.
But remember, going back to near normal does not mean pre-Covid normal. Do a personal risk assessment before attending a big event, tell your employer to invest in good ventilation and allow you to work from home when appropriate. Test if you have symptoms. Report the result and isolate if positive. Be kind and considerate, especially if someone asks you to put on a mask. Be safe.
Khairy Jamaluddin is Malaysia’s Health Minister. The views expressed here are the writer’s own.