ON March 15 and 16, 2020 Malaysia had recorded 190 and 125 Covid 19 cases respectively, after which the government announced a nation wide lockdown for a duration of two weeks from March 18 to 31, advising citizens to stay home, wear masks, practise social distancing of 1m, prohibition of mass movements and gatherings and allowing only essential businesses to be opened, and a sanction on Malaysians travelling abroad.

Within months Malaysia nearly won the war recording only double-digit cases and low number of deaths. Malaysia’s prescription for success received accolades from its own citizens, citizens of neighbouring countries as well as international agencies including the World Health Organisation. Malaysia’s Prime Minister was invited to share the nation’s success at an Asean meeting.

Letting the guard down and politics

After this success and with many letting their guard down and exacerbated by the Sabah elections, Malaysia had experienced an unprecedented increase in Covid-19 cases and deaths, initially recording for the first time, four-digit cases and thereafter reaching more than 3,000 cases on January 7.

On January 11, Prime Minister Muhyiddin Yassin announced that movement-control order (MCO) restrictions would be re-introduced to the states of Malacca, Johor, Penang, Selangor, Sabah and the federal territories of Kuala Lumpur, Putrajaya, and Labuan between January 13 and 26.

MCO 2.0 was instituted, but with less restriction on movement and allowing all businesses and schools to open. However under this much relaxed situation, Covid-19 cases did not go down as hoped but instead had kept on increasing till it reached over an alarming number, initially resulting in the government announcing it will not institute a third nation wide lockdown but only MCOs for selected areas with high covid cases such as Selangor and Kuala Lumpur.

Unprecedented increase to four-digit Covid cases

The rakyat watched in horror as Covid-19 cases escalated with no reduction in sight and no strict nationwide lockdown imposed. Many read with fear the cases of individuals who were aware of their condition but still persist to join gatherings, such as in Relau where more than 80% of the community were infected. There were instances where parents had requested for schools to be closed for fear of their children’s health and safety but were not heeded until Covid-19 cases had risen in schools.

The Health Ministry and the director-general of health Dr Noor Hisham Abdullah had made efforts to convey the seriousness of Covid via Facebook and just recently many of us had watched with grave concern the video shown on Covid-19 patients lying on hospital beds and his daily reminder for the rakyat to please adhere to the standard operating procedure and to be vigilant especially in view of Hari Raya Aidilfitri approaching. Many were horrified to learn that initially Raya was allowed to be celebrated, albeit with restricted numbers. We feared for the worse especially as Noor Hisham had forecasted that if SOP were not adhered to, cases would escalate further with the likelihood of Malaysia experiencing lack of beds and oxygen and surpassing India in covid cases per million population.

Malaysia’s fall from grace into another MCO

From being referred to as a nation nearly winning the war against Covid, Malaysia has now sadly been ranked third in terms of Covid-19 cases per million population, and potentially overtaking India, which is suffering severely from this pandemic.

In contrast from being commended by our neighbours previously, we now sadly acknowledge that a minister in one of our neighbouring countries had reminded and advised its citizens to strictly follow SOP and be vigilant so that they do not reach the state experienced by Malaysia presently.

Muhyiddin announced a nationwide lockdown on May 11 for a four-week period from May 12 to June 7. A ban on inter-district and interstate travel remained in place, dashing hopes of house visits to celebrate Raya.

A reference to Imperial College’s study on non-pharmaceutical interventions to reduce Covid-19 mortality and healthcare demand

Respected PM, leaders and members of the ministry and the National Security Council, I would like to make a reference to a study conducted by researchers from my alma mater, the Imperial College, University of London, United Kingdom. The report, titled “Non-Pharmaceutical Interventions (NPIs) to reduce Covid-19 mortality and healthcare demand”, launched in March 2020, based on epidemiological modelling had considered the impact of five different NPIs – case isolation in the home, voluntary home quarantine, social distancing of those over 70 years of age, social distancing of entire population and closure of schools and universities – implemented individually and in combination and describes the cost of inaction; in the (unlikely) absence of any control measures or spontaneous changes in individual behaviour, the team would expect a peak in mortality (daily deaths) to occur after approximately three months.

This report spotlighted that two fundamental strategies are possible:

• Suppression. Here the aim is to reduce the reproduction number (the average number of secondary cases each case generates), R-naught (R0), to below 1 and hence to reduce case numbers to low levels or (as for SARS or Ebola) eliminate human-to-human transmission. The main challenge of this approach is that NPIs (and drugs, if available) need to be maintained – at least intermittently – for as long as the virus is circulating in the human population, or until a vaccine becomes available. In the case of Covid-19, it will be at least a 12 to 18 months before a vaccine is available3. Furthermore, there is no guarantee that initial vaccines will have high efficacy.
• Mitigation. Here the aim is to use NPIs (and vaccines or drugs, if available) not to interrupt transmission completely, but to reduce the health impact of an epidemic, akin to the strategy adopted by some US cities in 1918, and by the world more generally in the 1957, 1968 and 2009 influenza pandemics. In the 2009 pandemic, for instance, early supplies of vaccine were targeted at individuals with pre-existing medical conditions which put them at risk of more severe disease4. In this scenario, population immunity builds up through the epidemic, leading to an eventual rapid decline in case numbers and transmission dropping to low levels.

The strategies differ in whether they aim to reduce the R0, to below 1 (suppression) – and thus cause case numbers to decline – or to merely slow spread by reducing R0, but not to below 1.

When examining mitigation strategies, the report assume policies are in force for three months, other than social distancing of those over the age of 70, which is assumed to remain in place for one month longer. Suppression strategies are assumed to be in place for five months or longer.

The aim of mitigation is to reduce the impact of an epidemic by flattening the curve, reducing peak incidence and overall deaths. Since the aim of mitigation is to minimise mortality, the interventions need to remain in place for as much of the epidemic period as possible. Introducing such interventions too early risks allowing transmission to return once they are lifted (if insufficient herd immunity has developed); it is therefore necessary to balance the timing of introduction with the scale of disruption imposed and the likely period over which the interventions can be maintained. In this scenario, interventions can limit transmission to the extent that little herd immunity is acquired – leading to the possibility that a second wave of infection is seen once interventions are lifted

Conditional on that duration, the most effective combination of interventions is predicted to be a combination of case isolation, home quarantine and social distancing of those most at risk (the over 70s). mortality. In combination, this intervention strategy is predicted to reduce peak critical care demand by two-thirds and halve the number of deaths. However, this “optimal” mitigation scenario would still result in an eight-fold higher peak demand on critical care beds over and above the available surge capacity in both Great Britain and the US.

Choice of suppression over mitigation

Given that mitigation is unlikely to be a viable option without overwhelming healthcare systems, suppression is likely necessary in countries able to implement the intensive controls required. The report’s projections show that to be able to reduce R0 to close to 1 or below, a combination of case isolation, social distancing of the entire population and either household quarantine or school and university closure are required. Measures are assumed to be in place for a five-month duration.

All four interventions combined are predicted to have the largest effect on transmission. Such an intensive policy is predicted to result in a reduction in critical care requirements from a peak approximately three weeks after the interventions are introduced and a decline thereafter while the intervention policies remain in place. While there are many uncertainties in policy effectiveness, such a combined strategy is the most likely one to ensure that critical care bed requirements would remain within surge capacity.

As the pandemic progresses, countries are increasingly implementing a broad range of responses. The study demonstrates that it will be necessary to layer multiple interventions, regardless of whether suppression or mitigation is the overarching policy goal.

However, suppression will require the layering of more intensive and socially disruptive measures than mitigation. The choice of interventions ultimately depends on the relative feasibility of their implementation and their likely effectiveness in different social contexts.

Recommendations for Malaysia

In view of the very high number Covid-19 cases currently experienced by Malaysia, I would like to offer the following recommendations:

1. Malaysia to impose the same strict restrictions as imposed during MCO 1.0, that is self-quarantine, wear masks, adopt social distancing, restrict mass movement and large gatherings, close schools and universities as well as non-essential businesses
2. Require social distancing of (now may be necessary) more than 1m. Many places now require 1.5m and some countries in Europe recommend 2m
3. Ensure clarity on existing MCO SOP to prevent confusion among Malaysians and international travellers
4. The government could request public and private media companies to share images of dire Covid situations in hospitals and other related conditions on national coverage to convey the seriousness of this pandemic to a wider audience
5. As priority must be offered to lives, sufficient support too needs to be provided to businesses, owners as well as employees to improve livelihoods. – May 15, 2021.

* Sheriffah Noor Khamseah Al-Idid Syed Ahmad Idid reads The Malaysian Insight.

* This is the opinion of the writer or publication and does not necessarily represent the views of The Malaysian Insight. Article may be edited for brevity and clarity.