MALAYSIA could continue to report daily Covid-19 cases in the thousands in the endemic phase, even after widespread vaccination, former deputy director-general of health Dr Lokman Hakim Sulaiman said.

The retired senior civil servant said unvaccinated children, along with existing and emerging variants of the virus could be contributing factors for new infections in the future.

“Cases may still be high if there are a sizeable number of unvaccinated adolescents and children who are susceptible.

“Secondly, Delta and new variants may cause breakthrough infections among the vaccinated. We saw this happening in the United Kingdom and Israel,” Lokman, now a professor at a medical university, told The Malaysian Insight.

However, the high number of reported cases daily should not be used as the only gauge of the severity of the virus, he added.

There are other key indicators to pay attention to when the country moves into the endemic stage.

This means that the coronavirus is here to stay but can be better managed so that its impact on the population is less severe and it becomes a “common” disease like the flu.

“What is more important is the capacity of the healthcare system to manage the numbers. Reported cases may be in the five digits but if a large majority are mild cases, which do not require hospitalisation, is it an issue?” he asked.

Lokman said the government must ensure that all levels of the health care system – prevention and control, primary care and tertiary care or intensive care unit (ICU) usage – are at the optimum to respond to any new surge in severe Covid-19 cases.

He listed six indicators he considers more useful than the number of daily reported cases:

• Duration of onset of illness to diagnosis (less than 48 hours)
• Diagnostic turn-around-time (less than 24 hours)
• Percentage of case registration backlog (less than 10%)
• Percentage of close contacts traced (more than 90%)
• Percentage of brought in dead (0%) cases
• Covid-19 hospitalisation rate (as per the World Health Organization’s recommend rate of less than 10 per 100,000 population to indicate moderate and focal community transmission).

After almost three months of recording five-figure new Covid-19 cases a day, Malaysia reported 9,066 fresh infections on Sunday.

The last time the nation reported such low levels was on July 12, with 8,574 cases.

Along with improving vaccination rates, the bulk of new cases reported daily have been in the less severe asymptomatic and mildly asymptomatic categories 1 and 2.

The national vaccination rate for the adult population is currently a little more than 87%, which is around 63% of the total population.

Explaining endemicity, Lokman said that it is geographically specific, and that some states may have reached an endemic stage while others have not.

Endemic states are where the level of immunity in the population is high enough either through vaccination or natural infection such that transmission is limited to the very susceptible.

“For example, Labuan has reached a high level of vaccination coverage among adults that protect them.

“Labuan also had very high incidence before the vaccination such that many of their children have been exposed to the infection in the previous wave and now have acquired some degree of immunity from natural infection.

“So, although vaccination among adolescents and children has just started, to me it is more like a booster because many of them could have already developed immunity from natural infection.

“Therefore, in Labuan they could have reached the endemic state.

“However, in Sarawak, cases are still high despite the high vaccination rate. Unlike Labuan, Sarawak is huge.

“So, I suspect the transmission which initially occurred mainly in urban areas is now spreading to other areas where there are still susceptible individuals.

“Due to logistical issues, the speed of vaccine coverage in Sarawak is not as fast as Labuan, and therefore, the speed of transmission has caught up with the speed of vaccination,” he said.

Will daily cases ever drop?

Lokman said whether the number of reported daily cases will drop any time soon would depend on the size of the population, speed and coverage of vaccination, type of vaccine used and size of the susceptible population.

“In most urban areas when transmission is more intense, the chances are quite a large number, including children, could have been exposed to and acquired natural immunity to the infection.

“So, infection will be sustained at a ‘low’ level. The incidence rate is a better indicator of disease burden than absolute numbers.

“The number of cases in urban areas may appear high but they have bigger populations, so the rate can be lower.

“In less urban and rural areas, adult vaccine coverage may still be low and the children are largely unexposed.

“So, the vulnerable population is still high in the areas. Thus, when infection is introduced an outbreak can easily occur,” he said.

Lokman said the speed of vaccination is key to prevent such occurrences and to reach the state of endemicity earlier, and lauded the government’s target to complete vaccination of all adults by the end of this month.

“If we can complete vaccination of adolescents and children by year end, then most states should reach the level of immunity and endemicity by that time. Yet again, speed of vaccination is the critical factor and of course, uninterrupted supply of vaccines,” he said.

Malaysian Medical Association (MMA) president Dr Koh Kar Chai agreed with Lokman, saying it would be difficult to predict when daily cases would drop given new mutations of the virus.

“Currently, we see a downward trend, but there may still be mutations and we have yet to see with certainty the level of protection against contracting the disease as opposed to the certainty that those vaccinated are protected against severe disease,” he said.

Moving forward, Koh said Malaysia should pay attention to Covid-19 hospitalisation and death rates.

He also said that monitoring the number of breakthrough infections will be essential as the country seeks to manage the endemic phase.

Genomic sequencing will continue to be needed to identify new variants for surveillance, he said. – October 6, 2021.