Analysis of Malaysia Pandemic Situation & 4th Series of #WeeklyThePurgeRecap

On 30th August 2021, I attended a virtual job interview for a digital healthcare company. They gave me two questions that they would like me to attempt to answer:

1.??????With the current COVID-19 Pandemic in Malaysia, can you please describe 10 strategies on how would you handle the Covid-19 pandemic in Malaysia?

?2.??????With the open-source data that is publicly available; can you do 3 simple analyses on Covid-19 that could be potentially useful & insightful for policymakers.

I would like to share my answers here as my first Linkedin article.

Also, I’ll consider this as my 4th (and final) series of #WeeklyThePurgeRecap. What is it, you asked? So, on 2nd of June 2021, Malaysia recorded its first >100 COVID-19 deaths per day. I kept track of those days and nicknamed it “The Purge”, reference to famous movie franchise.

Initially, I did it to raise awareness and, hopefully, pressure for the authorities to #Delaythatseconddose, reference to delaying the second dose of vaccine to 9-12 weeks (as were practice in the UK and Singapore) instead of the 3 weeks. During that time, vaccine supply was low and, instead of giving high immunity protection to a limit number of people, they delay the second dose to give sufficient immunity protection to a greater number of people. There were studies that suggested that 1 dose was effective to avoid death against the virus and a delayed second dose shown better immunity response level. However, during that time, Delta wasn’t dominating. With Delta, you need to be fully vaccinated to have a good chance of surviving. So, that idea was scraped. I still think we should have delayed the second dose in the early phase as UK did because it was effective against the other variants and we could have saved a lot of deaths, then.

Then for the past 1 month, I started #WeeklyThePurgeRecap, where I display simple graph/analysis of COVID-19 deaths in Malaysia of the week. However, with the COVIDNOW website and the recent announcement of backlogged death cases, I feel it’s fitting that this will be the last one. Looking forward to my next passion project!

Enjoy!

?DISCLAIMER: This was submitted on the 3rd of August 2021, therefore certain suggestions have been implemented since then.

QUESTION ONE:?With the current COVID-19 Pandemic in Malaysia, can you please describe 10 strategies on how would you handle the Covid-19 pandemic in Malaysia?

1.??????Leadership and Collaboration

We need a strong and confident leader to guide us during this pandemic. A leader that:

• ?Makes decision based on discussion with all Public Health experts (government & private sector) and the latest science and data
• Reassure the public of his team’s action plan
• Successful execution of the plan.

I would suggest an expert from the Public Health field since a pandemic does fall under public health. It is not a tumor that we could starve by locking down the nation. Like an Orthopedic specialist should only handle Orthopedic cases and not Internal Medicine cases, a Public Health expert should handle a pandemic.

The most important thing of leadership and collaboration is the sharing of data. A good leader is open to feedback and suggestion. Personal ego should be set aside for the nation’s interest. Multiple analysis from different parties and angles will increase our understanding of this disease and help our decision for our next step.

2.??????Towards Endemic: Stop the fear mongering & stigmatization

A leader shouldn’t use fear as an approach. This is the strategy that MOH has been using for the past year. Yes, COVID-19 is a scary disease and has caused millions of deaths. Yes, we need to be cautious and vigilant. However, fear indicates a lack of confidence and preparation from the ministry. The public needs to have confidence in the ministry in handling it.

Fear mongering strategy has also caused negative mental health impacts on an already burned-out nation. Increase calls on the mental health helpline and increase cases of suicides suggested that. Fear mongering strategy will lead to stigmatization when a person is confirmed positive. This is because the MOH has put the idea that a confirmed case is someone that is irresponsible by not following the SOPs. The SOPs reduce risk of transmission, but it doesn’t eliminate it. Being a confirmed case has already brought stress- prognosis, missing of work, risk of infection to loved ones-, the stress of the public’s stigmatization stress should not be added. No one asked to be infected. The MOH should provide support.

3.??????Increase testing, by encouraging testing

As we know, we can’t put all our eggs in the vaccination basket. “Finding, testing, tracing, isolating and supporting” (FTTIS) has been the bedrock of managing this pandemic since last year. With the aggressiveness of the Delta Variant and high positive rate, experts are urging for the increase of the FTTIS. However, there is still no solution on the how?

I would suggest for the government to encourage testing. Make testing as a new norm- test when you’re not well, test when you’re about to go to a mass gathering event, test a few days after attending a mass gathering event, test periodic (especially for the unvaccinated like children), and etc. As mentioned above regarding stigmatization, stigmatization would hinder for testing. That’s why we need to encourage by supporting and educating the public on the benefits of testing. Subsidies and incentive for test kit need to be introduced by the government. Currently, Saliva RTK Ag is available in pharmacies and it’s very convenient to do at home. Although the Health Minister has introduced a ceiling price for test kit, a further reduction of price would encourage the public for more testing.

4.??????A super contact tracing app with AI

To beat this virus, speed is key. However, MySejahtera, our main contact tracing app, hasn’t been performing as expected. This can be seen with our high positive rate, and it doesn’t look like it’s coming down anytime soon. We need a contact tracing app with incorporation of advance technology features like AI, big data, etc.

I elaborate more on this at the analysis question below.

5.??????Improve criteria for hospital admission

Our healthcare system is overwhelmed. This can be seen due the fact that we are on straight 50 days of more than 100 COVID-19 deaths per day. Our hospitals can’t keep up for now.

We need to improve our Home Surveillance Order (HSO) system- triage and support for the patients. We could introduce a Bluetooth token, like Singapore, to monitor patients for HSO. Virtual CAC has been introduced, virtual visit for HSO patients can be done. The government can provide oximetry and thermometer. NHS has a solid program for HSO – which is something we can learn and adapt to.

6.??????Vaccination: RampUp & Hyperdrives

States like Labuan and Sarawak are showing the results of high vaccination rate. Vaccinations do play a big role against COVID-19. States, like Johor and Perak, that have lower than 50% fully vaccination population are experiencing surge of cases and hospitalisation. Therefore, these states need to RampUp their vaccination rate.

Hyperdrive of vaccination is referring to vulnerable groups, such as young adults (12 years old-17 years old) and prisoners. As Malaysia to plans to re-open school in October, we really need to get eligible children for vaccination. More on this in my analysis below.

The second group are prisoners. There hasn’t been much focus on this group, but prisons/detention centres are high risk areas due to confined, closed, and crowded place it is. If a Delta Variant outbreak happen there, it will spread faster than wildfire. It’s a disaster waiting to happen. To avoid that, we need to start vaccinating them as soon as possible, especially the ones with co-morbidities.

7.??????Evidence-based Guidelines

One of the reasons we are in the situation we are in is due the ridiculous and confusing guideline that was place during the lockdown. It was not evidence-based guidelines (such as curfew of 8pm). We should be focusing on evidence-based guidelines such as ventilation guideline for closed space or testing guidelines.

8.??????Mental health support programs

The pandemic and the lockdown have brought a lot of negative impact and that includes mental health. Suicide cases has been on the raise and mental health helpline isn’t enough. Government needs to hold more patient engagement programs for mental health. To win this war, the mental health needs to be strong.

9.??????All hands-on deck

This is a war, no doubt. The frontliners are exhausted and understaffed. In a war, government draft young men to be sent to war. This should be done. If all sectors provide staffs that contribute to the fight against COVID-19, we will stand stronger. I’m not saying everyone wears PPE, but for example if you are computer software designer, contribute your skills in making a better AstraZeneca appointment website. If there’s no specific skills that could be contributed, an extra pair of hands at the field for testing or vaccination are always welcomed, but with proper training and briefing.

10.??Public Trust

Last year, I led 2 research projects on the knowledge, attitude, and practice (KAP) of Malaysian social media users on COVID-19 during MCO (NMRR-20-743-54644) and during CMCO (NMRR-20-1064-55142). Data collection was done for one week during MCO (17th April 2020-24th April 2020) and two weeks during CMCO (5th June 2020-19th June 2020). Data collection was made through Google Form and distributed via investigators’ social media platforms. During CMCO, 92.9% participants were confident that Malaysia will win the battle against COVID-19. The public trusted the government’s plan- they stayed at home, they obeyed the mask mandate, and they knew their 3Cs & 3Ws. As a result, we flattened the curve.

Then, the government became complacent. They held an election without proper and strict guidelines. Double standard cases increased. Confusing and non-evidence-based SOPs. The public requested for transparency and data, but none were given (until recently). Health education programs on COVID-19 stopped. Distrust grew among the public.

That’s what I would do differently. I would have maintained the public trust. I would have shared the data with the public and collaborated with other experts (outside of KKM). I would hold continuous health programs, for the public to stay vigilant, such as the 7 steps of hand wash/hygiene, the importance of ventilation on COVID-19, psychological support during prolonged quarantine/lockdown.

A study on public perception on the swine flu outbreak showed that that educating the public on reducing the risks of transmission and informing the government’s plans helped to improve compliance to good practices(1). Without the public trust and cooperation, we could have the best public health surveillance measures (PHSM) implemented, but we would still lose against COVID-19.??

QUESTION TWO: With the open-source data that is publicly available; can you do 3 simple analyses on Covid-19 that could be potentially useful & insightful for policymakers.

1.??????The importance of a sophisticated contact tracing system [MySejahtera vs SELangkah app]

I always wondered when did Selangor started to be the highest state of new COVID-19 cases. Last year, our biggest cluster was the Tabligh Cluster. On 19th May 2020, the Malaysian Director-General of Health Noor Hisham Abdullah stated that 48% of the country's COVID-19 cases (3,347) had been linked to the Kuala Lumpur Tablighi Jamaat cluster(2). Although Sri Petaling (the "crime scene")is located in Kuala Lumpur, Selangor would be hit quite badly due to its geographical location by Kuala Lumpur. However, it was quite will controlled. I believe SELangkah app played a role to this success because of its technology superiority on MySejahtera.

For this simple analysis, I extracted the new daily cases of Selangor (January 2020-August 2021) from the MOH GitHub. Prior to MKN’s order for compulsory Check-in via MySejahtera on 10th November 2021, there were high users of SELangkah apps for purpose of checking in at a premise. This led to a lot of SELangkah app user migrate to MySejahtera. Due to this and irresponsible order of not quarantine the Sabah voters returned to West Malaysia, Selangor cases raised exponentially.

There may be other factors that contribute to Selangor’s meteoric cases raise, however I believe the shift users from SELangkah app to MySejahtera played a role. This showed the importance of a sophisticate contact tracing system.

2.??????High positive rate reflects high deaths & brought-in-dead (BID)

WHO recommends a positive rate of less than 5%. A positive rate more than 5% indicates undetected cases and potential asymptomatic spreaders. Numerous pleas from experts to increase testing to lower the positive rate has fallen to deaf ears. Although we’ve seen links between positive rate and new peaks of new cases, it was defended that new cases are mostly in the lower category. For this next analysis, I compared August 2021 positive rate with deaths and BID.

Although the Pearson Correlation test (via SPSS) doesn’t show significant correlation (could be due to sample size), the graph and its trend cannot be ignored. In August 2021, we broke 2 records for highest death cases in a day and high BID cases. This was followed by peaks of positive rate.

With high positive rate, we’re not only not detecting asymptomatic cases, but high cases of deaths and BID to follow. We need to increase our testing.

3.??????It’s time to vaccinate children (12 years old-17 years old)

In this graph(3), it shows a huge increase of cases for under-18 this year compared to last year. This may be due to increase of testing compared to last year, however a lot of experts are pointing towards the dominating, transmissible Delta variant that we are facing this year. The Delta variant has been described as a “heat-seeking missile” targeting the unvaccinated. In view of reports of myocarditis case related to post COVID-19 vaccine on young adults (12 years old-17 years old), the MOH has delayed the vaccination on young adults even though it’s being reported that it’s a rare side effect.

Although most young adult COVID-19 cases recovered, sadly, mortality among them still exist. Also, reports on long COVID on them were reported and this may affect their development. With increase of cases, there will surely be an increase of deaths to follow.

As Malaysia plans to re-open school and the economy soon, we need to start vaccinating children as soon as possible. We must keep in mind of 3 things:

1.??????We are dealing with the Delta variant, not the Beta or Gamma variant from 2020. Delta is being dubbed as “the pandemic for the unvaccinated” or “heat-seeking missile” targeting the unvaccinated. These young adults fall into that. Channel 4 news estimated 150 children’s deaths a week due to the Delta variant in Indonesia(4). We do not want this to happen to our children in the first month of school re-opening.

2.??????Although there are concerns on myocarditis post vaccination, however it’s still quite rare compared to the risk of these young adults getting COVID-19. Other countries are pushing vaccination for children, and we should get on board. After 19 months of the pandemic, we should learn that we need to be more proactive, not reactive, to beat this virus.

3.??????Recently, as to ensure safety for children to return to school, MOH states that it will push for most staff in the school to be fully vaccinated. However, they fail to consider that there are parents that refused to be vaccinated. Also, having these young adults vaccinated could increase immunity coverage, covering the percentage of adult that refused/couldn’t get vaccinated. How do we mitigate the risk of transmission among children of unvaccinated parents and children of vaccinated parents? Yes, SOPs, physical distance, face mask, ventilation, and all that. But they are children who haven’t seen their friends for over a year. There won’t be an adult 24 hours monitoring them. Vaccinate them. Vaccinate them now.

If the ministry doesn’t start vaccination on these young adults soon, a school cluster outbreak will happen within one or two months of reopening. The worst thing is that they are still children. Children who depend on adult leaders to protect them but failed because they weren’t proactive enough.?

Well, that’s it. For a moment there, I felt like one of the decision makers at the top MOH table. With the whole Doctor contract issue, one can only dream though. Truthfully, my batch (the early intakes of contract doctors) will be the forgotten ones. Although, it was mostly us that went to the frontline during this pandemic last year, sadly, we will mostly end up at a private clinic due to no career progression and better pay. Most of us have left already.

However, the true victims are the Malaysians that can’t afford private healthcare due to lack of specialist in the public hospital in the future. Hopefully with the energetic and newly-appointed Health Minister, YB Khairy Jamaluddin, we’re on the right track on COVID-19 recovery and the contract doctor’s issue.

Although I haven’t heard anything from the company, I enjoyed the questions that were given to me. I definitely feel I can thrive in this role. Hopefully, I'll get an offer by end of this week. Why end of this week? Because by the end of this week, it would be 2 weeks since my interview and we all know, 2 week of silence is a response itself. It's okay.

“They plan, and Allah plans. Surely, Allah is the Best of planners.” Al-Quran 8:30

InsyaAllah.

Reference

1. ???????GJ R, R A, L P, S W. Public perceptions, anxiety, and behaviour change in relation to the swine flu outbreak: cross sectional telephone survey. BMJ [Internet]. 2009 Jul 18 [cited 2021 Sep 1];339(7713):156. Available from: https://pubmed.ncbi.nlm.nih.gov/19574308/

2. ???????COVID-19 pandemic in Malaysia | owlapps [Internet]. [cited 2021 Sep 8]. Available from: https://www.owlapps.net/owlapps_apps/articles?id=63136199&lang=en

3. ???????Over 310,000 Covid-19 Cases, 41 Deaths In Children This Year - CodeBlue [Internet]. [cited 2021 Sep 15]. Available from: https://codeblue.galencentre.org/2021/09/02/over-310000-covid-19-cases-41-deaths-in-children-this-year/

4. ???????Indonesia’s Covid disaster: Delta variant killing 150 children a week – Channel 4 News [Internet]. [cited 2021 Sep 8]. Available from: https://www.channel4.com/news/indonesias-covid-disaster-delta-variant-killing-150-children-a-week