We are now experiencing an exponential rise in confirmed COVID-19 cases. The numbers may appear staggering but in reality, the worse is yet to come. We are still in the early stages of this epidemic.
The number of new COVID-19 cases are increasing on a geometric scale. With some simplified conservative assumptions, on average, 2 cases infect 4 who then infects 8 who then infects 16; with each cycle taking 5-7 days. The increase in cases is gradual initially, but once there is an uptick, the increase in numbers can become very daunting.
A containment strategy was initially used to address this outbreak. Containment for COVID-19 is aimed at preventing it from spreading locally. A mitigation strategy aims to stagger the number of new cases over a more extended period enabling healthcare services to cope with a gradual rather than a steep increase. This epidemic will die out as more and more people get infected, recover, and are then immune to the disease (Herd Immunity).
The most effective preventive (Public Health) measures are those aimed at preventing the general public from getting infected. These Public Health measures include isolation, quarantine, and social distancing. Lockdown (curfew) is an extreme approach to implementing these measures. These terms are not synonymous and have different implications.
Isolation removes an infected individual from the population. Isolation aims to reduce the chances of the susceptible public from getting exposed to cases. In the initial containment stages of an outbreak, these cases may be isolated in the hospitals. In the later mitigation stages of an epidemic, there may be a need to triage hospital admission based on the severity of COVID-19 rather than just the presence of disease. Those with the mild disease should then self-isolate themselves.
Quarantine removes susceptible individuals who have been exposed to the disease and do not display any symptoms for 14 days from the last exposure. Quarantined individuals are served orders by the Ministry of Health to stay away from the public. Public health officers then conduct home surveillance of these individuals for the period of the quarantine. For quarantine to effectively control an epidemic, we need to effectively and efficiently identify the people who may be incubating the virus and ensure full compliance with the quarantine order.
Isolation and quarantine are critical preventive measures during the containment phase of an outbreak. As an outbreak evolves, there will be new cases with no previous (epidemiological) link to prior cases, and third and subsequent generations of disease transmission occur. This community transmission of COVID-19 leads to the need for a broader community mitigation strategy. Social distancing is one such example. It is different from isolation and quarantine as it emphasizes a collective responsibility and empowers the public to reduce COVID-19 transmission.
Social distancing reduces COVID-19 transmission by increasing the physical distance between people and the frequency of group gatherings. The aim is to reduce the likelihood of the public encountering a case. The Movement Control Order is timely and appropriate as there is an urgent need to slow down the disease transmission. The Movement Control Order uses 2 available legislations to address the community transmission of COVID-19 by Forced Social Distancing (FSD). The Prevention and Control of Infectious Diseases (Measures within the infected local areas) Regulations 2020 clearly defines the scope of the enforced travel restrictions and those who are exempted from this order. Though this order has the prerequisite legislative bite of the Police Act, Malaysia still needs each of you to follow the given directives.
The decision on an appropriate preventive strategy must balance the level of community transmission and impact of COVID-19 with the holistic cost of the prevention strategy. A lockdown (curfew), for example, appears on the surface to be the most effective preventive measure to reduce disease transmission. However, a lack of public buy-in and compliance will lead to it being ineffective in reducing disease transmission. Besides, there is a lot of direct and indirect negative cost associated with a lockdown. In an unprepared community, a lockdown may result in loss of economic output, increased psychological distress, and breakdown of social structures.
The numbers of new COVID-19 cases is rapidly increasing. At this rate, many of us will get COVID-19, approximately 15% of us who get infected will require hospitalization, and 2-5% will succumb to this disease. We need to accept that.
Our healthcare system has prepared for a pandemic scenario. However, health resources are finite at any one time. All of us have to play our part to flatten this epidemic curve over a longer duration of time. We can this by staying at home, shopping responsibly, staggering our shopping time, keep a distance of 3 to 6 feet when outside, and not going out if we are sick. The government tried voluntary social distancing, but it was ineffective. We now have Forced Social Distancing with the Movement Control Order. We all need to comply with these directives for a safer future.
Professor Dr Sanjay Rampal is a Public Health Medicine Specialist and Professor of Epidemiology at the Dept of Social and Preventive Medicine, University of Malaya. He is also Chair of the Public Health Society Malaysian Medical Association. Datuk Professor Dr Awg Bulgiba Awg Mahmud is a Public Health Medicine Specialist and Professor of Epidemiology at the Dept of Social and Preventive Medicine, University of Malaya. He is also the President of the Asia-Pacific Academic Consortium for Public Health-KL.
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