By Dato’ Dr Amar-Singh HSS (Consultant Paediatrician)
A COVID-19 disaster is looming in Malaysia as we watch the numbers rise. It is semantics to argue if we consider this a fourth wave or a resurgence of the third wave. What we know as a reality is that our control measures are no longer effective, deaths are increasing, younger people are dying (some with no chronic illnesses) and our intensive care units (ICUs) are getting choked. Our fear is not just death but Long COVID-19; i.e. 10-30% of all adults that get infected, even with a mild illness, may suffer long term damage to organs and be debilitated for many months.
It would be foolish to think that we cannot reach a state like India is in today. Don’t forget what happened to Italy early in the pandemic—they have much better health infrastructure compared to us and yet were overrun. Even recently, in the United Kingdom, ambulances carrying numerous COVID-19 patients had to queue to get access to hospital beds. Our national health services have been poorly funded with limited development for decades. If the current ‘wave’ escalates, our health services may have difficulty coping.
We need to work together concretely to mute this wildfire outbreak and work towards a COVID-19 eradication plan. It is unrealistic to depend totally on vaccination. The time has come to stop talking about herd immunity but eradication instead. I would like to offer some reflections and suggestions on the way forward based on current available science and data. This fresh crisis requires that we make a fresh attempt. Key useful measures to address the outbreak are highlighted under the headings below.
Mass Rapid Antigen Testing
We need to use extensive (blanket) rapid antigen testing as a critical part of public health measures to identify all infections possible. Contact tracing has failed as staff are overwhelmed by numbers. There have been a number of models and analyses to support that most countries pick up only a fraction of all cases (possibly 25% in Malaysia) and even COVID-19 deaths are under-reported. Our testing has been limited since the beginning. In April 2021, we did an average of 58,277 tests per day. Only in the past few days have we reached 80,000 tests a day, but is still far too small to make any impact on the raging pandemic. The argument from the authorities is that the positivity rate is around 3.5-5%, hence testing is adequate. But the reality of exponential spread in the community, and the failure of contact tracing, shows that we are not getting an upper hand over the outbreak.
We need to stop depending on the slow reverse transcriptase polymerase chain reaction (RT-PCR) tests but instead use rapid antigen testing (RTK-Ag) on people with or without COVID-19 symptoms. RTK-Ag may have a lower accuracy but it makes up in speed and impact. We should restrict and use RT-PCR as confirmatory tests only for hospital admissions i.e. in stage 3, 4 or 5 of illness.
If the Ministry of Health (MOH) is short on resources, tell the public. In my time in the civil service, I have often experienced the limited resources we had to deal with. We were often told to “manage with what you have”. If testing is hampered by funds, inform the public and they will be an advocate for MOH to get resources, or may even donate to support testing.
However, even blanket rapid antigen testing may not be enough; we need to learn from the countries that are now putting in place cheap mass weekly testing for office workers, students and teachers as a measure to work towards eradication.
Tracking Variants (Mutations) Actively
There has been much data from a number of countries to show that a number of significant variants of the COVID-19 virus have been responsible for a more rapid spread of and a more virulent version of the disease. We know that some of these mutations are circulating in our country. We require a more aggressive genome testing policy to track these and communicate real-time results to the public by location. If significant variants become widespread, they may hamper vaccination efforts and worsen the current outbreak.
Optimise COVID-19 Vaccination
We have had a slow start to our vaccination programme and have just reached 3% of the population with one dose, primarily due to supply issues. Currently, daily vaccination numbers are small and most vaccination sites are used sub-optimally. It does not make sense to keep vaccination centres open all the time and fatigue our health staff. It would be advisable to use up all available vaccines as quickly as possible by boosting staffing and efficiency at all vaccination sites; and then wait for fresh supply. This will provide a rapid rise in vaccination rates as well as offer staff at vaccination centres a break. We need to adequately support our health staff at vaccination sites as they are facing an enormous marathon.
We have seen how keen a segment of the public is to support vaccination from the AstraZeneca rollout. There must be a transparent mechanism for stand-by vaccination to cope with the 10-30% drop-out that vaccination sites are seeing. In addition, active reminders to those who have gotten a vaccination date and solving transport problems for the elderly and poor must be addressed. Backdoor vaccinations must cease.
We require transparency as to vaccination purchase, arrival dates and supply numbers by type of vaccine. This will offer hope to all our younger adults who are waiting patiently for Phase 3 to arrive.
Improve Risk Communication for Vaccines
We need to boost our risk communication for vaccines; currently it is very limited and simplistic. Just telling people vaccines are safe without offering good local data on side effects is not helpful. It is just like anti-vaccine proponents who say vaccines are unsafe without offering good data or by twisting the facts. We need to share detailed data on side effects openly to kill fake news and rumours. We have to address the reality that when we vaccinate millions, there will be a few who develop serious side effects, especially from unexpected allergic reactions and rare complications. Denying or minimising this is treating the public as infantile and encouraging the spread of fake news via peer to peer applications. Some nations have openly shared extensive adverse side effects—for example the UK Department of Health Yellow Card reporting system, Norwegian ADR Registry, South Korea Disease Control and Prevention Agency. It is time that Malaysia emulates them.
Effective SOPs, Timely Communicated
We currently have a huge variety of SOPs that are poorly communicated and often shared late. The current standard operating procedures (SOPs) are also inconsistent and at times not based on science and data. For more than a year, there has been a call for a simple, stand colour-coded SOP (as practiced in many countries) to upgrade or downgrade control measures dependent on the situation.
In the current crisis, it is long overdue to stop all indoor meetings, religious gatherings and activities of any size; they are the major spreaders of the outbreak. Only essential work activities that need physical presence like factories, food outlets, supermarkets, etc need to continue working at the premises. All others that can should be encouraged to work from home.
The only indoor meet that should take place are frequent parliamentary meetings. Parliament can convene as all members have been fully vaccinated. As long as they wear good-fit-masks, the risk is low.
Accountable Leadership and Oversight Required
Members of the public have a worsening trust deficit in current leadership, especially because of a failure of leadership by example; ‘do as I say not as I do’. The double standards that are widely evident have seriously hampered public compliance with SOPs. It is time to stop victimising the public and actively enforce SOPs among government ministers and leaders. The numerous indoor public gatherings organised by ministers should stop. All these are potential COVID-19 spreading events. The general public is willing to mobilise and face hardships for short periods if they see that their leaders are also involved in the struggle to contain the pandemic.
The emergency declaration has not proven effective in controlling the pandemic. We require external oversight and transparency. All elected members of parliament must meet for crisis discussions and a critical evaluation of current measures. We have empowered all of them to represent us and lead our nation.
COVID-19 is not an isolated issue confined to government or MOH, but an issue of immense national concern. All of us are intimately tied to this pandemic with our future and, at times, our lives at stake. The government of the day cannot dictate to us that they know best and impose their version of actions, without full transparency and external oversight.
We need all elected representatives, government or opposition,
we need all health care professionals, government, private, universities or retired,
we need the many people with ideas, from diverse occupations and backgrounds, from all over the nation,
to all provide ideas and support to end this travesty.