Covid-19 realities – safe workplaces and homes


THIS set of notes/ideas is styled as a FAQ and focused on how to understand Covid-19 better, vaccination (boosters, children), ventilation optimisation, improving home & office safety.

Important note: Information regarding Covid-19 changes rapidly and is very fluid. The pandemic is in evolution. Hence what is said today may need to be revised tomorrow. We need to follow ALL of the data, science and evidence; we cannot follow only part of the evidence.

Is the Delta variant more severe?

There is increasing data and clinical experience to suggest that the Delta variant is not just more contagious but more severe than the original Covid-19 virus. There is data from the UK to show that hospital admissions are twice as likely with the Delta variant than with the Alpha variant. A recent study from Canada showed that the Delta variant (compared to non-variants of concern) had a 120% higher risk for hospitalisation, 287% for ICU admission and 137% for death. Unpublished data from Florida showed 3.1-3.8 times higher mortality rates in children and young adults with the Delta variant. Our local data on deaths in Malaysia showed the huge escalation of deaths in the Delta wave – 76% of all deaths so far have occurred from July to September 2021, with one in five dead on arrival, one in three occurring in well persons (no comorbidities) and 45% under 60 years of age.

Remember that this is without vaccination – full vaccination reduces your risk of severe disease or death by 10 times.

Will I get a breakthrough infection after vaccination?

There is still some debate as to whether there is real vaccine waning immunity or if Delta is evading vaccination. There has been increasing data to show that at least one in three persons who are fully vaccinated with mRNA or adenovirus vaccines may get a breakthrough infection5 and that this rate is higher the longer the time from the vaccination date. However, the majority of the data supports that mRNA or adenovirus vaccines are still protective against severe disease and hospitalisation in the range of 85-95%. The data for long-term effectiveness of the Sinovac vaccine is still unclear. There is some suggestion from our local data that the effectiveness of Sinovac at preventing hospitalisation and ICU admissions is not as strong as the Pfizer or AstraZeneca vaccines.

As a higher proportion of the population is infected, we should expect that the majority of cases will begin to appear in the vaccinated (breakthrough) but will generally be mild. Vaccinated individuals clear the infection quicker; vaccinated individuals have milder disease and vaccinated people are less contagious.

This outlines the need for universal masking and maintaining critical SOP even after vaccination. In addition, to monitor the outbreak in Malaysia, we should also move away from looking at new cases to looking at new hospital admissions (see CovidNow website). And especially look at hospitalisation and severe disease in the vaccinated by type of vaccine.

In view of breakthrough infections, do I need a booster vaccination?

We need to follow the data (see above) and it suggests that vaccines are still protective against severe disease and hospitalisation. There is no evidence for routine booster as yet in the general population13. We cannot just rely on antibody waning studies but must also consider cellular immunity. Using antibody tests to identify those who need a booster is of limited value. Hence, we continue to require ongoing real-world data on serious illness with breakthrough infections (hospitalisation, death, long Covid). There is good data that immunocompromised individuals should receive a third dose (this is not a booster) as they do not respond well to two doses. There may be compelling reasons to boost frontliners as any breakthrough would impair their ability to work for 10 days, thus losing staff at critical workplaces. We need more data on the need for boosters in the public. But those aged over 60 years with underlying health conditions who received Sinovac may benefit from a mRNA or adenovirus vaccine booster.

We must remember vaccine inequity as we plan boosters – if we do not support other nations who have limited vaccine supply, new vaccine evading variants may emerge and damage the whole world.

What is possibly coming? Endemic Covid-19?

The future outcome of the Covid-19 pandemic is extremely difficult to predict and dependent on many factors like the:

  • degree of immunity from natural infection
  • duration and extent of vaccine protection (waning if any)
  • breakthrough infections and transmissibility of these
  • social contact and behaviour, including vaccine hesitancy
  • new variants of concern emerging (especially vaccine resistant ones)
  • new therapeutic options and the development of a pan-coronavirus vaccine,
  • and what burden of disease is acceptable and the healthcare capacity to cope

We hope to transition from a pandemic to endemic situation, where the virus is still circulating but sufficient individuals have immunity from vaccination and natural infection to lessen transmission, hospitalisation and deaths. The reality is probably a cyclic epidemic situation (hopefully diminishing over time) on top of an endemic rate.

However, in the meantime, those who are not vaccinated face a significant risk from the Delta variant. Of concern is a Delta pandemic among children as seen in some countries.

How can we protect our children?

It is good that we are vaccinating our adolescents, but we need to work to protect our children aged 0-11 years. As society and the economy opens up progressively, we have seen a higher proportion of children infected with more severe illness, ICU admissions and some deaths. A key proactive initiative we need to take is to ensure the safety of all our kindergartens and schools (primary and secondary), especially with regard to improved ventilation. Please see additional files on “Suggestions for Getting Children Back to School Safely” and “Ventilation-Air Filtration” that can be found here.

The key steps to take at kindergartens and schools are:

  • Improve the quality and fit of masks (remember to support children from poorer families).
  • Focus on airborne transmission and optimise ventilation in classrooms with a view to have fresh air exchange occurring at 5-6x air exchanges /hour/room (Harvard) or 10 l/s per person (DOSH). Keep doors and windows open and use outward-facing fans/exhaust fans at the window. Consider using portable air cleaners with good particle filters. Carbon dioxide (CO2) monitors as proxy indicator of poor ventilation.
  • Keeping students in a “Class Safety Bubble” to avoid mixing with other classes and limiting spread if one gets infected.
  • Consider weekly RTK-Ag testing for all teachers and students (especially for the unvaccinated kindergarten and primary schools).
  • Involve parents in decision making in schools, working very closely with teachers to get schools ready and maintain ongoing safety measures.

Apart from school, parents need to be aware of the risk to children from adult breakthrough infections and continue to be vigilant at limiting unnecessary social interaction and travel for adults and children.

How can I reduce my risk of breakthrough infections? How to make our workplaces safer? What is safe to do socially?

It is very likely that all of us will be exposed or infected by Covid-19 at some time, despite being vaccinated. We should aim to reduce the viral load we receive as this will potentially reduce severity. We would like to reduce our risk to other family members, especially those older with chronic illnesses and children. Some suggestions include:

  • Encourage everyone to be vaccinated.
  • Optimise the quality and fit of the mask you use. Add a face shield if possible.
  • Work from home as much as possible.
  • Consider weekly RTK-Ag tests for all staff if going to the office/workplace.
  • Maintain online interactions for conferences and meetings to limit travel and physical interaction with others.
  • Encourage unwell staff not to go to the workplace and give staff paid sick leave when needed.
  • Improve ventilation considerably with a target of 5-6x air fresh air exchange occurring every hour per room (Harvard) or 10 l/s per person (DOSH). Keep doors and windows open and use outward-facing fans at the window. Consider using portable air cleaners with good particle filters. Carbon dioxide (CO2) monitors as proxy indicator of poor ventilation.
  • Don’t eat lunch together with people outside of your immediate family (that’s when you unmask).
  • Avoid dining in unless the location has evidence of significant ventilation improvement.
  • Don’t unmask in public and workplace toilets (often a location with poor ventilation – put in exhaust fans).
  • Maintain your personal fitness, keep weight optimal, optimise the control of any chronic disease.

What do I do if I have a breakthrough infection (in those vaccinated)?

All of us need to be vigilant for any breakthrough infection. Recognise that this may happen in one in three vaccinated persons (or higher). The key seven symptoms that are predictive of Covid-19 include loss or change of sense of smell, loss or change of sense of taste, fever, new persistent cough, chills, appetite loss, muscle aches and sore throat. If you have any of these symptoms or have been in contact with a positive person or suspect you have Covid-19 you should:

  • Immediately do a RTK-Ag test, stop working, return home (private transport), self-isolate at home with a mask and keep away from other family members.

Once confirmed to be positive you should:

  • Isolate yourself in a room with attached bathroom for 10 days with good ventilation, contactless food delivery. If this is not available or possible then consider going to a quarantine centre.
  • Those who are positive and over 60 years of age and have significant illnesses (comorbidities) should consult a doctor about their quarantine location.
  • Notify the authorities using the MySejahtera application.
  • Inform all your workplace and family contacts (past five days) that you tested positive and encourage them to identify themselves as close contacts (using MySejahtera) and get an urgent RTK-Ag test.
  • Your workplace/office may need to close until testing results are back for all the staff, surface disinfection done (unnecessary if more 72 hours unused).
  • Anyone living in the same house as you who are high-risk or vulnerable (elderly or chronically unwell or pregnant) should consider living away from you for the period of the quarantine.
  • Monitor your oxygen saturation with a pulse oximeter three times a day.
  • Have a medical staff monitor your progress daily using a video chat.
  • Vaccinated individuals can return to work after a 10-day isolation, without testing, as they are usually no longer infectious. – October 12, 2021.

* Dr Amar-Singh HSS is a consultant paediatrician.

* 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.


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