In the past few weeks, there has been a sharp rise of newly reported cases, an increased number of tests that are positive, and increased mortality. The Test Positivity Ratio (TPR) on 9th July is 3.76 times that of 1st April 2021. The Case Fatality Ratio (CFR) in June had increased by 4.47 times compared to March 2021. Here are several possible interpretations of the current situation.
First, the true incidence is likely 4-5 times the reported cases in June and likely has carried over to July. The increased incidence may partly be attributed to the high community-wide transmission that is not being detected under our current screening strategy. The increasing cases may also foretell an even higher demand for healthcare in the coming weeks.
Second, the mass screening of higher risk areas during the EMCO had played a role in increasing cases, indirectly resulting in the sharp increase of Test Positivity. However, the TPR has only increased by 16% since the EMCOs in Selangor and WPKL. To conclude, EMCO likely increased the reported cases but did not fully explain the current increased incidence.
Third, the 4+ fold increase in CFR is troubling, but CFR may be highly biased by its denominator. If we miss cases, this will decrease the denominator and biased the CFR upwards compared to the actual Incidence Fatality Rate. The increasing CFR may be a marker of high under ascertainment of cases under the current screening strategy.
Fourth, the increasing CFR may also be a marker that the infection has relatively increased among our higher-risk populations (older, with medical comorbidities, those in nursing or care homes) in recent months. However, this is less likely among those who have been vaccinated.
Fifth, the rising CFR may also be a marker of the quality of care. If the healthcare system is highly strained, it may be time to rationalize healthcare. All those with mild or no symptoms should be isolated at home. The high community transmission greatly reduces the benefit of using our healthcare system to isolate cases. We should prioritize those that need intravenous medications, ventilation support, and ICU care.
Sixth, there is an urgent need to increase the capacity of our Public Health workforce. Testing capacity should be increased and become more affordable. Case notification and contact tracing should be conducted expeditiously. A better-equipped public health workforce will help the nation better mitigate this pandemic
Seventh, SOPs and interventions for this pandemic must be holistic and sustainable. There are many structural issues in our nation that affects health. We will not be able to overcome this pandemic by focusing solely on the virus. A broader, more integrated whole of society effort is needed. Pandemic management that emphasizes policing, enforcement, and high unreasonable penalties rather than compassionate health-promoting approaches only expediates pandemic fatigue, lowers trust and compliance.
Overview of the Epidemiological indicators for COVID-19
Incidence: The daily reported cases continue to climb since 25th June. A total of 9,180 cases were reported on 9th July that equates to 284 new reported cases per 1 million population. The number of active cases was 80,665 cases. Testing: The Test Positivity Ratio has been consistently higher than 6% since late May but has breached 9% this past week. The TPR was 9.4% on 9th July compared to 8.1% on 30th June 2021. Transmission: The time-varying reproductive number has been consistently elevated since 28th June and was 1.17 on 9th July. Mortality: The cumulative CFR remains low in Malaysia. However, the June-specific CFR of 1.28 was 4.47 times the CFR of March 2021 (Figure). March had the lowest CFR this year (CFR=0.29). The CFR is time-lagged due to its estimation method.
Dr Sanjay Rampal, Professor of Epidemiology and Public Health Medicine Specialist, Universiti Malaya. 10th July 2021.
The report is based on the information from Covid-19 Epidemiology for Malaysia dashboard and the Ministry of Health Malaysia.