[MALAY VERSION] We have reached a plateau, but we must do more to reduce the transmission rate, says Jeyakumar Devaraj.
This is an opportune time to assess the impact of the movement control order on the coronavirus epidemic as yesterday we ended the first movement control period, which the prime minister announced on 16 March, and we have just moved into the extended period until 14 April.
The graph below, which charts the number of new Covid-19 cases over the past nine days, suggests that the number of new cases daily has reached a plateau. This is different from the trajectories of the pandemic in Spain and in the US where the numbers are still rising.
New diagnoses of Covid -19 in Malaysia in late March 2020
The graph suggests that for the period 16-23 March (ie the likely period when the patients diagnosed in the last nine days of March would have been first infected), each new case was on average passing the infection to one other person before being diagnosed and isolated – a transmission ratio of 1.0.
This is better than the transmission ratio quoted by epidemiologists, who have worked out that, in the absence of control measures, each Covid-19 patient would on average infect 2.6 other persons before being diagnosed and isolated. This 2.6 transmission ratio would double the number of new cases every four days, pushing up the number of new cases exponentially.
But it is not enough to bring the transmission rate down to 1.0. We need to bring it down further if we want to reduce the number of new cases.
If we could push down the average transmission rate to, say, 0.8, this would reduce new cases by 20% every six days. The impact would be cumulative – 0.8 at day six, 0.64 at day 12, 0.54 at day 18, 0.44 at day 24 and 0.35 at day 30 (of the number of new cases on day zero). So, if we attained a 0.8 transmission ratio, we would reduce our new cases from 150 daily to about 53 in a month’s time (150 x 0.35).
The movement control strategy alone may not be enough to achieve this. It keeps people confined in their homes and guards against the transmission of the infection to 10, 20 or more people attending the same mass function. The strategy has played a major role in bringing the transmission rate down to 1.0.
We now need to figure out how to push the transmission rate even lower. The National Security Council (NSC) does not appear to have thought this through properly so far. Their recent statements have focused on tightening restrictions and using more punitive measures to enforce them. This has made life more difficult for ordinary citizens. We do not need to do this.
The NSC has to change tack and identify smarter and more effective measures to bring the transmission rate down. A good place to start is to ask: how are people still getting infected despite movement control being in place?
I believe they are getting infected in two ways:
- from contaminated surfaces in shops, groceries, banks and markets that they visit to obtain essentials
- from an infected family member who lives in the same home
We need to address both these ways to push the transmission ratio below 1.0.
The NSC should seriously consider the following additional measures.
1. Masks for all those venturing out of their homes
Some of those now catching the coronavirus bug probably got their hands contaminated with the virus when they went out to banks, grocers or wet markets.
The problem is that when people get infected with Covid-19, they might not realise they are infected for the first few days. They might feel normal, but they may have already started shedding the virus, especially in the later part of the incubation period. When they go out to the grocers or markets, they can contaminate surfaces without realising it, and this might infect others using the same facilities.
We can markedly reduce the incidence by requiring all to wear masks when they enter bank, grocers and supermarkets. The masks, in this case, are not to protect the wearers but to trap the infected droplets they might emit, ie the masks are to protect other people.
As the aim is to prevent droplets from contaminating surfaces, simple homemade reusable cloth masks will suffice. That will be much cheaper and will not worsen the shortage of the proper N95 masks that healthcare personnel require. We can clean these cloth masks by soaking them in warm soapy water for 30 minutes before washing and reusing them.
Requiring everyone to wear masks could be a game-changer.
2. More effective quarantining of contacts
At present all household contacts of a confirmed case required self-quarantining, ie they are supposed to stay in for 14 days, strictly. But is this being done adequately?
Proper self-quarantining requires that each person in that affected household to have his or her own room with an attached bathroom. Most homes in Malaysia do not have such facilities. So there is a high risk that the contacts would infect each other. The first confirmed case in the family might just pass the infection to one other person in the household. But because of the cramped living area, eventually most household members would turn positive.
Is the Ministry of Health and the NSC looking into this? A number of hostels were identified for the purpose of quarantining contacts. Are they being used? Perhaps we need to leave the mother and the children aged below 18 in their own home and provide them provisions regularly.
But other members of the household should be required to move to the hostels for the 14-day long quarantine period. The government should provide their meals and other basic needs.
The Ministry of Health and the NSC should continually assess the adequacy of the quarantine effort. How many identified contacts are there for each diagnosed case? How many of them are under a proper quarantine? What is the rate of infection among contacts? Are some states or districts performing more poorly on these scores?
Break the data down to the district level and use it to spot outliers so that remedial action can be taken. If necessary, more staff should be deployed for this important effort of quarantining contacts more effectively, so we cut further transmission of the virus.
3. Earlier testing of symptomatic cases
We should carry out “PCR-RNA” tests, which detect the coronavirus’ genetic material, ie RNA, on all those who have any two of five symptoms: fever, cough, sore throat, body ache and loss of smell.
Unfortunately, even now, the government sector is short of the reagents used for the tests. And so, government hospitals’ outpatient departments withhold these tests from patients who do have these symptoms simply on the grounds that they have no history of travel to certain countries or contact with a known Covid-19 cluster. This leads to delays in the diagnosis and isolation of positive cases.
Meanwhile, going for swab tests seems to have become a bit of a fad for the well-heeled who do not have any symptoms. Some private hospitals are promoting such tests, with several even organising drive-in tests (at a fee of around RM550 per person). Such testing wastes scarce resources and should be discouraged. People should be told that testing negative for Covid-19 today does not protect them from getting Covid-19 tomorrow or the day after.
Early testing has an important role to play, but clinical criteria must drive it – not the ability to pay or commercial considerations. The government must put more money into doing PCR-RNA tests for all patients with suspicious symptoms. Earlier diagnoses will enable earlier isolation and reduce the chances of virus transmission.
4. Winning the trust of the migrant worker population
As argued above, the key to controlling the Covid-19 epidemic is a combination of early diagnosis, efficient contact tracing and effective quarantining.
But two-thirds of some six million migrant workers in our country do not have documents and live in fear of the authorities. So can we really implement the above control measures for them?
If we fail to get their support and cooperation, the migrant worker community might well turn out to be the Archilles heel of Malaysia’s Covid-19 control programme. This is a serious issue, but the NSC appears reluctant to tackle it holistically.
A Ministry of Health circular dated 29 January 2020 says treatment of all migrant workers would be free if they are diagnosed with Covid-19. But the same circular says that if they are not Covid-19 cases, they would need to pay the charges specified in the 2014 new fee implementation guidelines, ie Garis Panduan Perlaksanaan Caj Baru (2014).
These charges are several times higher than the fees Malaysian citizens pay. Any delay in seeking treatment because of a fear of the high charges would lead to the rapid transmission of Covid-19 once it spreads to the migrant worker population (as it is likely to do).
The People’s Health Forum submitted a memorandum to the NSC on 19 March 2020, which proposed two main measures to handle coronavirus control among the migrant worker population:
- Suspend the 2014 fee schedule for migrants
- Impose a moratorium on arrests and imprisonment for immigration offences for the next one year
These two initiatives, together with approaching the migrant worker population through their informal associations and NGOs, might help our health department gain their trust and cooperation regarding self-referrals, testing, contact tracing and quarantining.
Incidentally, quarantining will require placing them in quarantine hostels as they generally live in extremely cramped conditions. If we fail to develop this trust, we could see an explosive spread through this stratum of our society – which would then require more economically debilitating movement control in the future.
It would be in our “enlightened self-interest” to implement the two measures suggested by the People’s Health Forum. We hope the NSC will take this issue seriously. It would be silly to be penny wise and pound foolish.
So, to answer the question posed in the title of this article, yes, we have markedly slowed the transmission of Covid-19 in Malaysia. And we should give credit to the Ministry of Health, the NSC and the public for this.
But we need to do more – we must bring down the rate of transmission to 0.8 or lower so that the number of new cases starts falling. It is important we do this as soon as possible, for many are finding the movement restrictions painful.
We need to restart our economy so it can produce goods and services for our people and so that families are able to work and earn money to meet their needs.
Families going hungry
The Socialist Party of Malaysia (PSM) has one final request for the NSC: do urgently address the fact that some families have run out of food.
Daily rated workers, rubber smallholders, micro-business owners in night markets (pasar malam) and casual workers are facing problems as they cannot work, and they did not have much savings to start with. Families are approaching PSM branches throughout the country, asking where they can get help.
It is good that the PM’s economic stimulus package announced on 27 March 2020 includes a cash transfer of RM1,600 to four million poor families, but this will only be rolled out in late April. That is far too late for the families now facing a cash crunch.
Can the NSC look into this urgently as a large number of families are affected? Surely the details of the BR1M and BSH (handouts to cover cost of living) recipients are already in the government database. Why can’t the cash transfers begin in the first week of April? It would make a great difference to these families.
We are midway through the movement control period, and we are making some progress. Let’s stay the course, cooperate with the authorities, stay indoors as much as possible, but also reach out to families in need of food and other basic supplies.
There are many challenges ahead. Reviving the economy amid a global recession will be another huge problem after we emerge from the movement control order. But nothing is insurmountable, if we address it on the basis of solidarity and science.
Hang in there!