We have had sustained local transmission of COVID-19 for 17 months and have had two large outbreak waves since the Sabah Elections. There is also an increasing number of SARS-CoV2 variants of concern. In addition, the disease has become entrenched in our communities with higher rates of community transmission (unlinked or sporadic cases). Approximately 7 out of 10 cases in the last month was an unlinked case. COVID-19 will be here for the next many years.
We have learned so much more about the disease. However, pandemic management globally is complicated by fear, groupthink, poor governance, weak leadership, political gamesmanship, lack of critical insights, cohesiveness, integrity, and transparency.
Reported cases are not a good indicator in the long term for SOP calibration. The actual effect of vaccination on long term incidence is uncertain. Vaccination will have a short-term impact of drastically reducing transmission, but that is likely to wane with time and newer strains. Newer strains that escape the current vaccines will likely predominate future infections. Therefore, it is tough to achieve herd immunity against COVID-19 due to the increasing variants. Vaccination is still essential but more in the sense that it dramatically reduces the severity of cases. Following immunization, a lot fewer COVID-19 cases may get complications and require hospitalization. As a result, the daily reported cases lose their significance as an indicator for disease morbidity.
ICU utilization is a downstream effect of transmission. It may take 3-6 weeks between an intervention and its impact on ICU utilization due to the lag between the incubation period and the need for ICU care. This prolonged duration makes ICU bed utilization a poor indicator for most real-time decisions. Better upstream indicators for SOP calibration includes test positivity ratio, case notification within 24 hours of a positive test, and contact tracing within 48 hours of a positive test.
Preventive public health services are one of the most sustainable interventions during this pandemic. As we may have to weather this pandemic for the coming years, there is an urgent need to increase the capacity for preventive public health services. A better-equipped public health workforce will decrease the likelihood of future lockdowns.
Movement restrictions have been in place for the past 17 months. The effectiveness of movement restriction is highly dependent on the rate of community transmission. Intense movement restriction during the first MCO for a prolonged period was very effective because community transmission of COVID-19 was rare. This latest lockdown (MCO 3) has not been as effective, partly due to the decreased intensity that allowed more movement by the working population to lessen its financial and economic impact. Due to its reduced effectiveness, FMCO/National Recovery Plan Phase 1 will require a more extended period to bring the cases down. In addition, the impact of these latest movement restrictions is likely transient due to the high community transmission; cases are likely to increase with its lifting. Thus, movement restriction is now an inferior intervention due to its decreased effectiveness, temporary effect, and high cost. We should use it ever so rarely as a form of total lockdown (think MCO1) in times of emergency.
The community is the most critical element of this pandemic. Unfortunately, the constant high intensity of the interventions has created pandemic fatigue among the community. Pandemic management that authoritative and top-down may not get the necessary buy-in from the community for the long term. Emphasis on policing, enforcement, and high unreasonable penalties rather than compassionate health-promoting approaches reinforces this disconnect with the lay man. Ultimately, this may lead to a loss of trust that results in poor compliance by the community.
We have to learn to live with this virus. A big issue has been the perceived severity of this disease. The infection fatality rate is very low among those aged 50 and below. Therefore, we should consider relaxing the SOPs on completing Phase 2 of the National COVID-19 Immunization Program. High-risk groups, including senior citizens, those with co-morbidities and people with disabilities, would have been vaccinated, resulting in a lower need for hospitalization.
Globally, many countries will face prolonged psychological, social, financial, and economic problems due to the maladaptation of their society to the virus for the long term. Effective and efficient public health services, completion of the immunization program, evidence-based time-varying SOPs will likely help us better adapt to a future with COVID-19. The faster our Nation adapts to the virus, the better our overall outlook for the long term.
Dr Sanjay Rampal, Professor of Epidemiology and Public Health Medicine Specialist, Universiti Malaya. 14 July 2021.