Why are COVID-19 cases still high in Sabah?

The introduction of the CMCO in Sabah with localized EMCO and TEMCO should decrease the intensity of transmission. However, we continue to see a high number of cases because of a few reasons:

First, the time lag of one to two weeks delay between an intervention and its effect of the virus spread. Thus, we need to be patient when starting or changing interventions.
Second, there were large proportions of cases arising from clusters within closed system populations such as prison and detention centres, etc. These closed systems are likely to be densely populated and may have different characteristics to the rest of the populations. It may be very difficult to control COVID-19 transmission within these closed systems. It is imperative then to prevent the spread of disease to the community from these closed systems by effective prevention among those who are working in these centres.
Third, difficulty in implementing prevention and control activities due to localized issues.
Fourth, there is evidence of increasing community transmission. The establishment of community transmission make prevention and control activities difficult through conventional Public Health activities.

Containment vs Mitigation

There are at least two major strategies to the prevention and control of COVID-19 during this pandemic. A containment strategy aims to first eliminate transmission and then to prevent local transmission. This strategy is associated with higher cost but has direct tangible benefits in preventing current infections. An issue with this strategy is that during this pandemic, the risk of COVID-19 is globally present and that a large proportion of the population remains susceptible to this disease. Waves of large outbreaks are difficult to prevent because even when local transmission is elevated, good border control is needed to prevent importation. A mitigation strategy becomes useful when containment is difficult and unsustainable. The interventions under a mitigation strategy aims to slow the transmission (flatten the curve) so that the healthcare system can optimally manage covid-19 cases.

Should we consider mitigation strategies for prevention and control of COVID-19 in Sabah

Community mitigation becomes important during this pandemic when containment becomes difficult. The mitigation measures may vary from community to community due to the uniqueness of different communities. A “one size fits all” solution becomes difficult. In the case of Sabah, there are many unique problems and issues due to the heterogenous environment and socio-cultural backgrounds. More resources may have to be invested at the community level in a bid to empower them and build community resilience

It was reported that Sabah has a capacity to actively manage 8,375 cases including 1,007 hospital beds allocated for COVID-19 care in 9 hospitals, 28 quarantine and low risk treatment centres. This appears sufficient at this point of time. However, we may have to consider a change in strategic approach if there is a further increase in daily cases in Sabah. One option is to reserve Hospital care based on triaging of medical needs to those with moderate or severe infections. Those who are at low risk can be isolated at home. Keeping a case in the house will raise questions of transmission but a mitigation mindset balances that harm with the benefits of greater healthcare availability those more severe patients. The family members of that house will have to be further quarantined from the larger community. Larger communal living quarters does increase the complexity but can be addressed by quarantining all members.

In more dire scenarios, low risk and quarantine centres can also be modified to accept higher risk populations and reserving hospital only for those that need intensive care.

If the number of cases increase, it becomes more likely that more ICU beds will be needed. The current 133 ICU beds will have to be greatly increased to accommodate the larger number of active cases. To this end, MOH appears to be planning for this by increasing ICU capacity at the nine hospitals in Sabah.

Prepared by Prof Dr Sanjay Rampal, 31 October 2020.

Reference:

1. https://twitter.com/DGHisham/status/1322021097810767873

*Parts of this opinion was first published by Code Blue on the 29 October 2020