Let us together flatten the COVID2019 epidemic curve
Dato’ Dr Musa Mohd Nordin
Damansara Specialist Hospital
13 March 2020
The WHO officially declared the outbreak of the novel coronavirus 2019 as a pandemic on 11 March 2020. This is the second in the 21st century after the HiN1 influenza pandemic in 2009.
The Ministry of Health (MOH) Malaysia, marshaled by the past Minister, Dr Dzulkefly Ahmad, was on the ball, immediately after the announcement of the first Wuhan case of COVID2019 on 31st Dec 2019.
It is pertinent to take stock of our current containment and mitigation strategies and benefit from best practices elsewhere, to craft our Malaysian plan of action against the SARS-CoV2 pandemic.
We should first try to understand current and best knowledge of this coronavirus which is bewildering most scientists studying it.
The SARS-COV2 is a very smart coronavirus. It does not overkill it’s host unlike SARS-CoV1 and MERS-CoV. Its Case Fatality Rate (CFR) is 2% when compared against 10% for SARS and 35% for MERS.
It therefore lives another day to further infect more humans. This is reflected in its Ro (Reproduction Nought) of 2-4, an index of how contagious the virus is. Contrast this to the less infectious MERS (Ro less than 1) versus the extremely infectious measles virus with an Ro of 13-18.
The mean time from exposure to the manifestation of symptoms, namely fever, cough and breathing difficulties, is 7 days, with a range of 2-14 days.
However, it is now established that he SARS-CoV2 is able to infect others even prior to manifesting clinical symptoms. Analysis of 124 Wuhan cases with clearly documented contact history illustrated an incubation period of 5 days (ranging from 1-11 days). It also showed that 73% of secondary cases were infected before the onset of symptoms in the index COVID2019 case.
This suggests that a substantial proportion of secondary transmissions was acquired prior to the onset of clinical symptoms and signs in the index case. Experts best estimates is that 12% of carriers can spread COVID19, 2-4 days before the manifestation of the signs and symptoms.
This existence of asymptomatic transmission of SARS-CoV2 makes total containment very difficult and problematic.
In the light of these disclosures of the transmissibility (and fatality) of the SARS-CoV2 we may need to realign and reconsider some of our strategies of containment and mitigation.
I do not think we need to follow the draconian, lockdown methodology of China and Italy. South Korea has been very successful in reducing confirmed cases of COVID2019 from 900 per day to less than 100 per day and declining further. Probably we could learn from some of the salient features of South Korea’s strategy to “flatten the COVID2019 epidemic curve”
We should continue to screen, through fever checks and rt-PCR testing, detect the positive cases and isolate cases. Self-quarantine should be advised in appropriate clinical settings
We should ensure that there is sufficient, rapid and accurate diagnostic test kits and which is undertaken appropriately to conserve the supply chain. South Korea undertakes 12,000 – 20,000 tests per day. Prior to the lockdown of Italy only 20,000 tests were done. Due to restricted and flawed test kits only 4,000 tests were done in the USA prior to the declaration of global pandemic. The US CDC therefore does not have an idea of the burden of COVIC2019 disease in their community, which makes it very difficult to solicit public support for their ensuing public programs.
To facilitate testing South Korea has organized several Drive-Through SARS-CoV2 tests at public areas. This Drive-Through model has been replicated in KPJ Damansara Specialist Hospital (KPJ-DSH) and Hospital Sungai Buluh. In fact, KPJ-DSH has operated mobile Drive-Through COVID2019 testing at several Government Linked Companies (GLC) premises, as part of testing of persons in close contact with Index Case 26.
Dr Dzulkefly during his stewardship of the MOH emphasized transparency of their work processes, which seems somewhat alien to the work culture of most government ministries. He pushed for the public release of the findings of the independent investigation of the fire incident in HSA in 2016 despite fierce protests from the top officers in the MOH. Tan Sri Abu Bakar Suleiman, vice chairman of the fire investigation commission and myself, as part of the now defunct Health Advisory Council (HAC), advocated for the prompt and complete release of the fire report.
This transparent work culture permeated through Dr Dzul’s handling of the COVID2019 disease outbreak. Apart from being transparent, he made sure the information was accurate, readily accessible and presented in a reassuring and calming manner.
This is extremely crucial, because quick access to accurate information is powerful in debunking fake news and fear mongering. It empowers the rakyat to be active partners of the MOH and the government in the fight against the outbreak
Another strategic decision that needs to be carefully considered is the shift from the imposition of physical and legal barriers towards creating healthy social barriers as advocated in the infectious disease philosophy of social distancing.
The cities that practiced social distancing during the Spanish Flu pandemic in 1918 suffered the least impact from the effects of the H1N1 influenza outbreak.
These social distancing strategies ranged from best practice hygiene practices, cough etiquette, avoidance of large crowds, no handshakes, hugs and kisses, replaced with Hola, Namaste and Eyvallah, staying home when unwell, wearing a mask if unwell and still needing to be out, staying put in homes for high risk groups eg pregnant ladies, geriatrics, those with underlying health conditions, work from home, cancelation of all large events eg games, religious congregation, conferences, to more major closures of schools, theatres, mosques and churches.
Manual contact tracing can be very laborious and time consuming and may still not track the vulnerable persons. It is time for the MOH to utilize GPS technology and information for contact tracing.
In South Korea, all travellers entering the country are recruited into the Self Health Check Mobile App which not only tracks the visitors’ symptoms but also his whereabouts. This has caused some embarrassment in certain circumstances eg those who frequented love hotels etc and has raised issues of invasion of privacy and confidentiality.
And I would like to suggest to the MOH to utilize the Artificial Intelligence (AI) expertise of the likes of Dr Dhesi (previously digital health advisor to Dr Dzulkefly) to team with the group in UMMC under Prof Adeeba to get cracking towards AI
AI modeling, tracking and forecasting of COVID2019.
All of these interventions I believe, will help to flatten the COVID2019 epidemic curve, to delay and spread out the progression of the outbreak, reduce the disease morbidities and mortalities and reduce the burden on our healthcare institutions and essential services. This hopefully will buy us some time until anti-viral agents and a vaccine can be produced and its manufactured up-scaled for global treatment and protection