We are now into day 7 of our movement control order (MCO) to prevent spread of the coronavirus (COVID-19) in Malaysia. If we want to get it right and make the best use of the MCO we need to listen to good international experts and nations that are able to control the epidemic.
There are three important key strategies in stemming this epidemic: Strong and transparent leadership, physical (social) distancing, and testing.
We are attempting to enforce physical (social) distancing with our MCO and 'boots on the ground' and we hope all Malaysians play an active part and not continue with disbelief, denial and disregard of the importance of doing this.
Leadership has been a serious problem for our nation and this crisis exposes fully the weakness. Many of us will have watched with envy the wonderful interview BBC did with the South Korean Foreign Minister Kang Kyung-wha. Her strong leadership is a major reason the coronavirus outbreak is controlled in South Korea. She explains the basis of their strategy: "the basic principle is openness, transparency and fully keeping the public informed". She also expressed that 'extensive testing has been the key to South Korea's low coronavirus fatality rate'. We need this in our country.
In this article I would like to focus on testing – who we are testing, our testing capacity and how to improve it. Being critical of our abilities is not aimed to defeat them but to ask how we can put in place the optimal strategies that will give us the best outcome. MOH is doing extensive work amidst a very difficult situation. Our aim is to support and improve our efforts.
Dr Mike Ryan, the World Health Organization's (WHO) emergency expert says very clearly that a 'lockdown' of nations alone is insufficient to stem the coronavirus spread. He says "What we really need to focus on is finding those who are sick, those who have the virus, and isolate them, find their contacts and isolate them…" and "The danger right now with the lockdowns ... if we don't put in place the strong public health measures now, when those movement restrictions and lockdowns are lifted, the danger is the disease will jump back up."
Tedros Adhanom Ghebreyesus, the WHO Director General, said "We have not seen an urgent enough escalation in testing, isolation and contact tracing, which is the backbone of the response". "We have a simple message for all countries: Test, test, test. Test every suspected case. If they test positive, isolate them and find out who they have been in contact with two days before they developed symptoms and test those people, too…"
We appear to have some testing capacity but those of us who are trying to make sense of the numbers are concerned. The Ministry of Health (MOH) stated in the press conference yesterday that they are doing 3,500 daily currently and hope to ramp that up to 16,000 a day by April. Some are showing a graph comparing us to Italy and showing that we have less of an escalation than them and suggest MCO is working, but you must remember that in this coronavirus outbreak you get the data you test for. So are we testing adequately? One international database suggests we have tested only 13,000+ as of 20th March 2020.
With the virus spreading wider in the community it is important that we test, at the very least, three groups of people:
1. All contacts of those found to have the virus (positive) or at risk
This means testing not just the contacts who look ill but also those who look well (asymptomatic contacts). In addition we need to test all those who are coming back from high risk countries/locations. The MOH policy has been to test only those who are symptomatic contacts or symptomatic at risk travellers only (see MOH guidelines). This is of concern as the experience from Wuhan, Italy and other location shows that about 30-40% of those infected remain largely well (or developed symptoms later), especially those who are younger. However these individuals may be important in the spread of the virus to others and account for between 10-40% of the epidemic. We cannot control this epidemic if we do not test all contacts (ill or well) of an infected person or traveller from a high risk location.
2. Tests all healthcare professionals (HCPs) who are unwell
HCPs are our last line of defence in this epidemic. If they go down we lose the opportunity to save lives. Many frontline HCPs have expressed that they are not able to get a test when they feel unwell (fever or a respiratory illness). We are currently only testing those who have come in contact with a positive case, but this is insufficient at this stage of the epidemic as we cannot trace where some people get their infection. Our national influenza surveillance (ILI/SARI) shows at least 1% are positive for COVID-19 in the country. We have to assume that the virus is spreading in the community. In addition we have irresponsible individuals that lie about their contact history. Of even more concern is the desperate shortage of personal protective equipment (PPE) all over the country for HCPs. I am seriously worried that so many have had to resort to home-made PPE which cannot be said to be safe and effective in protecting them. Once one HCP is infected the risk to others in that facility is huge and it hampers the functioning of the health facility for days. We cannot control this epidemic if we do not immediately test all HCPs that become mildly unwell, regardless of their contact with infected cases.
3. Test all viral pneumonias
In the face of community spread, we need to test all patients who present with a severe viral infection (influenza-like) or pneumonia. We have to make the assumption that all such individuals have COVID-19 until proven otherwise. We cannot allow these individuals to be housed in our normal wards or be treated in outpatient with other persons (not to mention the risk to HCPs). We cannot depend on a history of travel or contact with proven cases. Currently we are NOT doing this. We cannot control this epidemic if we do not test all severe viral infections (influenza-like) or pneumonias that present to clinics or hospitals.
An important message to remember about testing is that one negative test does not mean you are not infected. We see many individuals expressing they have been tested and are clear of the virus. We know from the experience in Wuhan, China that some only became positive after testing 2 or 3 times, as the virus may be in the incubation period and the test is only positive later. So the question to ask is, have we been re-testing those who were negative again and again?
I would like to end by speaking a little about the potential growth and impact of this outbreak. When testing numbers are limited, as in Malaysia, we may get a better idea of the outbreak by looking at deaths and ICU admission. I have plotted two graphs (attached) – one that shows our outbreak in comparison to selected neighboring countries and another that tracks our ICU admission and deaths. The rapid escalation of deaths and ICU admission suggests our epidemic is growing fast.
I was recently misquoted by some in social media after an interview with Astro Awani, possibly because they did not listen to the full interview. Allow me to summarize our plight in a fresh way. Remember these figures as we work as a nation to address this threat to our families, our economy and the fabric of our society: 80%, 15%, 5%, 1%.
For every 100 infected persons, 80% will do well, 15% will be ill enough (respiratory problems) to need admission and oxygen, 5% will require ICU care and ventilation (machine support), 1% will die.
The 1% is a conservative figure assuming world class facilities and the availability of ICU care for the 5% of those who get ill. Do we have this scope of facilities when many become ill? Hence IF 60% of our population gets infected then we can expect at least 200,000 deaths. This is a very conservative number as we cannot provide ICU care for so many, even over time. It all depends on how well we control and limit our epidemic. In addition don't forget all the regular admissions and ill patients we will need to deal with. Some may die because we are managing the coronavirus outbreak.
As for solutions to improve our response I would like to offer three suggestions.
Firstly, I would like to echo the WHO Director General, in saying "Test, Test, Test". Let us work together to increase our testing capacity now, not tomorrow. Let us not be shy to buy test kits from other nations (South Korea, Taiwan, China). Our very rich individuals and companies play a vital role to get this done. I recognize they are reluctant to donate money, as they are afraid it will be misused but we can advise them which tests to buy and donate them to MOH. Private laboratories can also play an important role here. Few can afford the RM 700-900 for a test. Consider slashing your prices down to a bare minimum of RM30-50. You have been earning from the public for years, time to give back to the nation in its time of desperate need.
Secondly, we need to harness all the smart and kind people in our country, many of whom have a lot of time on their hands, to support us during this epidemic. Civil society organizations (CSOs) have been organizing practical support for the poor, disabled and immigrants. Others have mobilized to support HCPs. Some have been creative in mapping out this epidemic, see one good example here. Others, like 'Think City' are working on mapping vulnerable populations and offer information to government for decision making. There are many more who are available and willing to support the government's initiatives to end this outbreak. We have only need to ask for help. We don't have to go through this alone.
Thirdly, we will need to extend the MCO for another 4 to 8 weeks, painful as that sounds. The mad exodus a week ago, the gross delay in finding those from the tabligh cluster and their mobility, the lack of finding links to some cases, all tell us that we will have a larger wave of cases coming in the next 2-4 weeks (with serious case 2-3 weeks after that).
In the coming weeks and months everyone will probably know one person who is infected, if not our family member or ourselves. I pray that we do not come to the place where every Malaysian knows one family member or friend who dies from this outbreak. We have the capacity to stop the coronavirus outbreak, but only if we choose to work together.
(Dato' Dr Amar-Singh HSS is a Senior Consultant Pediatrician.)