By Xavier Kong
WHILE Phase 2 of the Movement Control Order (MCO) is coming to a close, it has been confirmed that the MCO will be extended until the end of April. As it is, the Academy of Medicine of Malaysia is already calling for the MCO to extend beyond Hari Raya, citing the dangers of the exodus to and from hometowns.
“The current MCO must continue beyond the current Phase 2 period ending on April 14. For public health reasons, the ban on non-essential interstate travel must continue, leading up to and beyond Hari Raya Aidilfitri, which is expected to fall on May 24. Other celebrations such as Hari Gawai and the Harvest Festival will also follow soon after this period,” the academy had said in a statement dated April 9.
As this statement was received with discontent, the question now being bandied about is whether or not the MCO is actually effective.
Datuk Dr Amar-Singh HSS, a retired paediatrician who has written extensively on Covid-19, told FocusM that, while there is no doubt that the MCO has been effective, there remains no evidence that the numbers are coming down.
“It was a difficult decision to put the MCO into effect, but it was a necessary move. The MCO remains a critical step in breaking the chain of infection, but we have inadequate data to say how long it would last. As it is, the numbers reported do not reflect the epidemic because we are testing inadequately,” he said, noting that there has been no significant rise in testing, and that all pneumonia cases should have been tested six weeks ago for the possibility of Covid-19.
Dr Amar is a senior consultant paediatrician who has served more than 35 years in the civil service. At the time of his retirement, he was the Head of the Paediatric Department at Hospital Raja Permaisuri Bainun, Ipoh.
As of 12pm, April 12, Health director-general Datuk Dr Noor Hisham Abdullah shared that the total number of confirmed cases has reached 4,683, with 153 new cases reported. Of those, 2,108 have been discharged, including the 113 new recoveries that day. Of the 2,499 being treated, 66 are being treated in the intensive care unit, with 37 needing ventilator support. The death toll has also reached 76, with three more deaths from the virus.
He also shared that the infectivity of Covid-19 in Malaysia has been brought down due to the MCO, stating that, before the MCO was implemented, each patient would infect 3.55 people. However, with the implementation of Phases 1 and 2 of the MCO, that has been brought down to 1, with the expectation (as of April 10) that the figure will be brought to 0.9 by April 14, meaning that each case will infect less than one person.
A healthcare professional (HCP) who wishes to remain unnamed has also called for more data to understand the epidemic and make decisions regarding the relaxation of the MCO, including performing testing on several groups, such as all persons who have come into contact with Covid-19-positive persons in the last two to three weeks, whether they are symptomatic or not.
The HCP noted the examples of the 66 policemen who were confirmed Covid-19-positive, with 1,225 contacts that have been quarantined, but no information on whether or not the contacts had been tested. Another concern raised here was on the tabligh gathering participants who have yet to be tested. Though all participants had been screened, not all have been tested for Covid-19, and “the low numbers in Kelantan is of concern in view of this.”
All travellers, whether symptomatic or not, should also be tested upon their return from any country where there is an extensive spread of Covid-19, as well as all patients with pneumonia and severe influenza-like illnesses. The number of pneumonia cases from January to April 2019 should also be compared to the numbers for January to April 2020 to see if there has been an increase.
Lastly, the HCP also called for all currently working HCPs who develop any respiratory symptoms or fever to be tested, as they are also a part of the frontline in screening patients.
‘Pending test results mask actual numbers’
Another matter Dr Amar reiterated was the issue of pending cases, which he said needs to be brought as close to zero as possible.
“Pending cases mask the actual numbers, and the time it takes for the test results to come back limits the people on the ground and hinders their ability to make good decisions regarding their patients,” he said.
As it stands, according to Dr Noor Hisham, Malaysia’s testing capacity stands at 11,500, with the director-general of health aiming for 16,500 as more laboratories join up. He also shared that testing is also being conducted at higher numbers over the days.
Another issue here is the tabligh group cluster, of which not all of the attendees were tested yet. Of these, only the symptomatic ones have been tested, and there are those who have yet to step forward. This can also cause complications, as the effectiveness of the polymerase chain reaction (PCR) test, which is the primary method of testing for the Ministry of Health now, will be lowered to about 50% after eight to 10 days have passed from when symptoms first show.
When asked what this will mean for the asymptomatic cases, Dr Amar pointed out that, by the end of Phase 2 of the MCO, not even all of those displaying symptoms will have been discovered, considering the fact that not all of the pneumonia cases are being tested.
“The targeted contact testing being conducted by MoH is insufficient for finding each person,” he noted.
This has now been further compounded with the news that there are sub-clusters detected at several madrasah and tahfiz schools in Pahang, Penang, Melaka and Selangor, which was announced by Dr Noor Hisham during the daily Covid-19 update on April 12.
The source of infection at these locations is from close contact with participants of the tabligh gathering at Sri Petaling. This marks an additional 195 cases coming from the Sri Petaling cluster, and further emphasises the importance for all attendees of the tabligh gathering who have not stepped forward for testing to do so.
Still, Dr Noor Hisham has shared that portable rapid test kits from Korea are being deployed on April 13 which can return results within an hour, though he also warned that the search for an “accurate and reliable test kit” is still ongoing. There is also word that there are plans to manufacture a test kit design from the US, though there are still obstacles facing this due to the intellectual property of the kit, as well as the reagents which have to be sourced from Taiwan. Both of these require talks and authorisation to obtain.
MCO extension woes
As of April 10, Prime Minister Tan Sri Muhyiddin Yassin has announced a further extension of the MCO by another two weeks, with the MCO now slated to end on April 28. Muhyiddin noted that this would allow healthcare workers space to combat the Covid-19 epidemic.
On this topic, Dr Amar noted that there is already news that the marginalised communities and lower-income segment are not getting what they need. He pointed to a report about how food was not reaching the Orang Asli, and that those with no resources would be hardest hit by an extended MCO.
“If the MCO is to be extended, the government needs to show that they are adequately supporting these categories of people, but while support is coming from the government, it is not comprehensive enough, and is not reaching all of those who need it. Immigrants and daily rate workers are also part of this concern, as they are constantly losing resources while being unable to work,” he said.
He also warned about the dangers of other illnesses as a side effect of the Covid-19 pandemic. Someone with symptoms of other diseases that could very well be chronic or progressive in nature, such as cancer or diabetes, could decide to not head to the hospital to check on a possible symptom, leading to late discovery and lower chances of recovery or controlling the disease.
There is also a need to address the issues of mental health. While counseling services with emotional and psychosocial support are offered by the government, there are also those mental health issues that require medication to control. These patients who suffer from invisible illnesses will undoubtedly be victims of Covid-19 as well, though from a different aspect of it.
Preparation
As it stands, with the MCO extended by another two weeks, Dr Amar noted that this period should be used to prepare the public for post-MCO life, as well as ramping up testing capacity to perform mass testing.
“The MCO is to buy time to do things. As it is lifted, it should progress to localised MCOs with rapid response teams to take care of flare-ups,” he said, adding that the MCO has to be relaxed progressively in stages, and not all at once.
The announcement of the MCO extension was also accompanied by the prime minister asking Malaysians to prepare for a long haul. Dr Amar believes this to be true, that Malaysians could well be looking at “one, maybe two years” of facing down Covid-19.
“We have to make sure we can handle every wave coming in, and these waves will be coming in the foreseeable future,” he said, warning that this would need Malaysians to go through change and practise self-discipline.
This includes maintaining strict social distancing as part of a long-term lifestyle change and making the cleaning of hands and surfaces normative. The use of masks must also become commonplace, and the development of mass testing capability and rapid response coronavirus teams for precision quarantines will be necessary as well.
He also lauded the statement made by Dr Noor Hisham, about no gatherings for the next six months, as a good warning for Malaysians to prepare themselves.
“The Covid-19 pandemic has changed our lives, and we will have to adapt,” said Dr Amar. – April 13, 2020
