We all know we are in this pandemic for the long haul and may need to maintain prevention measures for the next two to three years. This means we need sustainable measures that all of us can adhere to and keep for another two to three years. No one can predict what is going to happen in the next 12 months. Will a viable vaccine emerge? Will the virus change or mutate further? One thing is sure: we will get a second wave and a third wave and a fourth wave. Our aim must be to keep these outbreaks to the bare minimum.
The reasons we are in a better place than some other countries in dealing with this crisis is due to the movement control order (MCO), the hard work and sacrifice by Health Ministry staff, and public cooperation. There is also some good data emerging that suggests that the Covid-19 mutation spreading in our region is a milder variant with a lower mortality. But this does not mean that other mutations with greater severity will not reach our shores.
However, it is perhaps our low numbers that are now causing many people to let down their guard and stop wearing masks. In addition, fatigue has set in and we have become weary of constantly maintaining our vigilance against this virus. But people must realise that the community spread of Covid-19 is still ongoing – much of it asymptomatic – and we could have a flare up at any moment (as now seen in Kuching).
We would like to highlight some important issues that need our consideration, thinking and dialogue as a society.
How best to monitor the pandemic when case numbers are low
There are three aspects of data to monitor in keeping track of the pandemic locally.
The first is to look out for all unlinked cases. These are individuals who test positive but are not linked to any cluster. For example a person being admitted into hospital for an operation who tested positive (there have been a number of these). Or a prisoner about to be transferred is tested positive. All unlinked cases indicate a much larger unrecognised community spread of Covid-19. Their numbers may be small but their implications are huge.
The second type of data to look for are infections that are occurring in locations where there is the potential for explosive spread, or where fatalities may be high. It is concerning that two prisoners, in two separate prisons (in Sabah and Kelantan), tested positive. We urgently need follow up testing data for both locations to see how many individuals within these cramped, crowded locations are positive.
The third set of data to monitor are the types of Covid-19 mutations that are circulating in Malaysia. In light of growing evidence that severity and fatalities are influenced by mutation type, we need to know which mutations are circulating and whether new mutations have entered the country.
Testing capabilities for subsequent waves of infection
Initially, we took some time to ramp up testing, and results were very slow in coming back (turn around time); we were also slow to expand into critical areas. We have now improved but appear to have stagnated in total testing capacity. We have been informed for some time that we have the ability to do 37,000 PCR tests a day (hopefully with a less-than-24-hour turn around time). But is this sufficient if we experience a large surge in cases?
A number of countries in this region have significantly increased testing capacity so that they can do large numbers of tests daily. We need to keep growing our testing capacity and exceed 100,000 tests a day to be able to deal with impending subsequent waves if they come in greater numbers.
Even more worrying is the drop in daily testing numbers. From accessible data (from the Health Ministry's Facebook page), we currently use less than 20% of available tests. We are not using our tests fully when numbers are apparently low. But now is the time to use all our tests to explore widely and minimise community spread. We should test all frontliners, not just those in hospitals, but police and service individuals (supermarkets, food industry, etc). We should also do exploratory testing, especially among the immigrant population (only 65,000 tested as at July 15, 2020).
Aggressive testing may have small positivity rates but the returns in stopping community spread may be large, as seen in New Zealand and Taiwan.
How good are our physical distancing measures?
During the initial MCO phases we were “forced” to comply. With relaxation in subsequent phases, we find many becoming complacent or using masks as a proxy. Masks are very useful but being vigilant about safe physical distancing measures is equally vital.
At times we appear to be giving mixed messages: We allow 100% occupancy of air-conditioned aeroplanes, trains and buses but do not permit children in open air playgrounds. We see ministerial and government agencies meeting in closed, air-conditioned rooms, often sitting closer than 1m but families going out to have a meal together may be fined RM1,000 each for not sitting apart. We have allowed the resumption of larger religious gatherings and have yet to address the “super spreading” locations where people are in close proximity like prisons and illegal immigrant detention camps.
All this suggests we have much to improve regarding safe physical distancing measures.
The introduction of the routine use of masks outside the home is a good and welcome measure in view of asymptomatic spread. It is an important tool in the prevention of Covid-19, especially as safe physical distancing is very difficult in mass transport, smaller offices and crowded public spaces.
It is sad that we have not introduced routine mask use in all our schools, in view of data from South Korea and Israel that show schools are an important part of the resurgence of Covid-19 cases in those countries. Face shields used together with masks are also helpful for higher risk individuals or those with greater exposure like frontliners.
There are, however, many issues that must be addressed with the implementation of mandatory face mask use. Most of us will still remember the poor old Chinese uncle who was arrested when he went out to find food during an MCO period. We are concerned that the poor will not be able to afford masks, hence they may be victimised by this measure. There is no way for the poor (B40 group) to comply with this ruling without a government mandated free programme. Singapore has an excellent system which has dispensed six cloth masks to every citizen. However, locally some of us have yet to receive the four masks promised to all households nationwide in April 2020.
There will also be a need for a system to exempt some individuals from wearing face masks. Having looked after children for much of my medical life as a paediatrician, I recognise that children with cardiac and respiratory diseases and those who are significantly disabled have difficulty wearing a mask; at times it may be harmful. This would also apply to some adults. Children under two years should also not wear masks. Hence we need an exemption system to be put in place urgently before the mandatory ruling comes into effect.
In addition there are rumours currently circulating about the requirement to only wear three-ply surgical face masks. We need to have clarity on this issue. It may be dangerous to require the use of only three-ply masks as many cannot afford them and will resort to reusing and recycling them, which is hazardous. Already we see such masks used for the whole day or ironed/sunned and reused. There is also the issue of fake three-ply surgical masks for sale, especially online.
There are many false graphics circulating about the efficiency of different mask types. We need to retain the N95 masks for medical personnel. Three-ply surgical masks are more effective than cloth masks but cloth masks are useful and there is a growing body of data showing their value. See these reports, studies and summary of the evidence: one, two, three, four, five.
In case anyone thinks we cannot deliver free cloth masks to every Malaysian, especially the poor, have a look at the achievement in Singapore and the Czech Republic. Remember that in March 2020 the people of the Czech Republic made hundreds of thousands of cloth face masks for all their citizens and distributed them within five days.
Mask etiquette and government leaders
The media is full of poor mass etiquette by our political leaders. Both the government and Opposition members of Parliament are united in their failure to use masks or their failure to use them correctly. It is dangerous to wear your mask around your chin and then pull it up to your face as you may infect yourself; however, many MPs are doing this. Leaving your nose exposed defeats the function of masks, yet some MPs do this. If you want the people to wear masks, leaders must first lead by example.
We must apply the same set of rules to our leaders as we do to the people. If the people are fined for breaking prevention measures, then the leaders must also be fined. In fact, we expect a much higher standard from our leaders. They must set the example so that people will follow. Blaming the public alone for lack of cooperation is not acceptable. Members of the government and the public must share the responsibility for lapses in prevention measures.
We need to encourage each other as we try to deal with the chronic fatigue and depression that comes with this pandemic.
DATUK DR AMAR-SINGH HSS & DATIN DR LIM SWEE IM
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