Should the CMCO be extended?

There is an increasing number of queries on the necessity for more intense and restrictive SOPs. One way of rationalizing these top-down policies is to understand how the pandemic affects us. The COVID-19 pandemic poses a significant threat to our health, economy, and security.

The following indicators evaluate the COVID-19 threat to our health:

  • The COVID-19 burden to the healthcare system. The total active COVID-19 cases and those who require more intensive support is a measure of the overall load. Mitigation aims to avoid the overwhelming of our healthcare system capacity. The nation has a current capacity to manage 16,060 cases comprising of 3,825 hospital beds and 12,235 quarantine and low-risk beds (DG tweet, 30 October 2020). Assuming 15% of cases require hospitalization, the current system may be able to manage a total of 25,500 active cases. However, capacity is not uniformly distributed and varies by region. 
  • The intensity of COVID-19 transmission (Ro/Rt) – Is there a change in the daily reported cases from week to week? The Ro is the average number of people who get infected from a previous COVID-19 case in approximately a week. Various factors influence the reproductive number; including the virus and environment factors such as crowded work or living quarters/hostels and closed system populations such as prison or detention centres. The reproductive number is very susceptible to changes in screening strategy. Reproductive numbers tend to dramatically increase during specific active case detection activities; for example, testing of a whole village or prison. The reproductive number, as an average measure, also does not correctly account for super spreading events.
  • Baseline risk of COVID-19. We all take this risk of getting infected by coming out of our houses. It may be measured using a density measure of infection. When all cases are isolated, this risk is estimated using the number of new cases/100,000 population.
  • Risk of unmitigated community transmission. The number of new cases that cannot be linked to any previous clusters is a good indicator of community transmission. These cases may be identified either by symptomatic screening, screening of Severe Acute Respiratory Infections (SARI); or through pre-operative screening. These cases usually represent a much larger number of undiagnosed cases in the community. Community transmission can exponentially increase the generation of new cases.

We have focused on the health threats of COVID-19. We will let other experts elaborate on the COVID-19 threats to our security (including national, political, and food security) and economy.

Decisions on SOP intensity will need to prioritize the different indicators of health, economy, and security and concurrently balance the benefit to harm ratio of the proposed policy. Prioritization will differ based on one’s perception. Different priorities may result in the formulation of various policies from the same data because of how we weight the relative importance of these domains. However, variation in perception may also promote innovative insights and out of the box solutions.

So, should the CMCO be extended in either Sabah or Selangor, WP KL, and WP Putrajaya? The short answer is that it depends on the region’s situation. The benefit to harm ratio of a lockdown will typically be higher when the composite health threat is higher. For example, based on the COVID-19 trends in Sabah, a CMCO extension or intensification is justified based on current healthcare availability, the intensity of transmission, risk of community transmission, and persistence of community transmission.

Prepared by

Dr Sanjay Rampal, Professor of Epidemiology and Public Health Medicine Specialist, and

Dr Vivek Jason Jayaraj, Public Health Doctoral candidate,

Department of Social and Preventive Medicine, Faculty of Medicine, University of Malaya, 6 November 2020

*Edited version of this opinion was first published by The Star on the 6 November 2020