A Further Extension of the MCO is Inevitable

As at the time of writing, the Movement Control Order (“MCO”) is expected to be in place until 14th April 2020.[1] The Health Director General, however, has not ruled out the possibility of a further extension of the MCO. It is all dependent on whether Malaysia succeeds in flattening the curve and preventing any exponential spikes, thus breaking the chain of infections.[2]

It cannot be denied that COVID-19 is highly contagious. The virus has an estimated R naught of somewhere between 2.0 and 2.6,[3] with the average being 2.2.[4] This means that for every 1 infected person, COVID-19 could spread to 2.0 to 2.6 other people.

Early figures have shown that the MCO is successful in flattening the curve.[5] However, the World Health Organisation has also stated that it expects the number of COVID-19 cases in Malaysia to peak in mid-April.[6]

Apart from the expected peak in cases, a persuasive reason for extension in and of itself, the following are some reasons why a further extension of the MCO is inevitable.

There are untested infected individuals

With regard to the tabligh cluster, the Health Director General stated on 27th March 2020 that 13,762 individuals were screened with 9,327 samples taken to be tested. 1,117 of the samples tested positive, 5,646 tested negative, while 2,564 were still pending results.[7]

As at 28th March 2020, 5,084 individuals connected to the tabligh cluster (including attendees, their family members, and other close contacts) had yet to be tested.[8]

1,117 out of the 6,763 individuals whose results are available were found to be infected with COVID-19 (16.50%). Assuming 16.50% of the remaining 7,648 individuals (2,564 awaiting results and 5,084 untested) from the tabligh cluster are infected with the virus, this would mean an addition of approximately 1,262 COVID-19 cases.

Not forgetting individuals who may have contracted COVID-19 from inter alia having travelled overseas.

Some of these untested infected individuals may be asymptomatic. Others may only have mild symptoms and are able to manage their illnesses at home.[9] However, during that time, these untested infected individuals will certainly be in contact with their family members who may then be out and about during the MCO period thereby further spreading the virus.

There are false negative infected individuals

Individuals who have tested negative for COVID-19 could also subsequently test positive. This has reportedly occurred in Japan[10] and Australia.[11]

Carolyn Y. Johnson, a science reporter at The Washington Post notes:

“There are a number of reasons a test might be negative when a person is sick with the coronavirus. It might be too early in the illness, when the amount of virus in the airway is still small. It could be a problem with how the swab was done. Different types of swab collection — the back of the nose, the throat, the outer nose — may also have different levels of accuracy, an issue doctors are actively debating given limited evidence. Then, there could be issues with the handling or transport of the swab. There could be laboratory error.”[12]

There are MCO-period infected individuals

It is reasonable to assume that there will be individuals who contract COVID-19 during the MCO as people are inter alia still allowed to leave their homes to purchase, supply or deliver food or daily necessities.[13] Some of those individuals may be asymptomatic and are unknowingly spreading COVID-19 to those around them.

A number of researches have shown that the percentage of asymptomatic COVID-19 cases is not negligible. According to a study which looked into 575 Japanese nationals that were evacuated from Wuhan, China:

“Using a binomial distribution, the asymptomatic ratio is thus estimated at 30.8% (95% confidence interval (CI): 7.7%, 53.8%) among evacuees.”[14] (emphasis added)

Conclusion

In view of all the above, if the MCO were to be lifted on 14th April 2020 and Malaysians return to their routines pre-MCO, this could be the start of the next wave of COVID-19 cases which will undo the hard work and results achieved in the four weeks of the MCO. The entire healthcare system could be overwhelmed as seen in Italy[15] and Spain.[16]

In light of COVID-19’s incubation period, the MCO should only be lifted when there have been x consecutive days of no new infections (a figure to be decided upon by virologists and epidemiologists).

On 24th March 2020, the Chinese Government announced that the lockdown in Wuhan will officially be lifted on 8th April 2020.[17] This comes after Wuhan reported no new cases of COVID-19 through domestic transmission from 18th March to 22nd March.[18] Even then, experts have warned that zero reported cases does not equate to zero risks.[19]

Therefore, economic impact notwithstanding, it is inevitable that the MCO has to be further extended until COVID-19 is truly under control.

[1] Mazwin Nik Anis, “MCO extended to April 14 (updated).” TheStar.com.my. The Star. Accessed March 31, 2020. https://www.thestar.com.my/news/nation/2020/03/25/mco-extended-to-april-14

[2] Nuradzimmah Daim, “Dr Noor Hisham: Too early to decide on MCO extension.” NST.com.my. New Straits Times. Accessed March 31, 2020. https://www.nst.com.my/news/nation/2020/03/579644/dr-noor-hisham-too-early-decide-mco-extension

[3] "Coronavirus: How deadly and contagious is this COVID-19 pandemic?" ABC.net.au. ABC News. Accessed March 31, 2020. https://mobile.abc.net.au/news/2020-03-22/covid-19-how-deadly-and-contagious-is-coronavirus/12068106?pfmredir=sm: "The reproduction rate (also called "R0" or "R naught") is somewhere between 2 and 2.6."

[4] Marco Cascella; Michael Rajnik; Arturo Cuomo; Scott C. Dulebohn; Raffaela Di Napoli, “Features, Evaluation and Treatment Coronavirus (COVID-19).” ncbi.nlm.nih.gov. National Center for Biotechnology Information. Accessed March 31, 2020. https://www.ncbi.nlm.nih.gov/books/NBK554776/: “... the basic reproduction number (R0 - R naught) is 2.2. In other words, on average, each patient transmits the infection to an additional 2.2 individuals.”

[5] Joseph Kaos Jr., “Health Ministry figures show Covid-19 curve is flattening, says Health DG.” TheStar.com.my. The Star. Accessed April 2, 2020. https://www.thestar.com.my/news/nation/2020/04/01/health-ministry-figures-show-covid-19-curve-is-flattening-says-health-dg

[6] “WHO expects Malaysia's coronavirus cases to peak in mid-April.” StraitsTimes.com. The Straits Times. Accessed April 2, 2020. https://www.straitstimes.com/asia/se-asia/who-expects-malaysias-coronavirus-cases-to-peak-in-mid-april

[7] Rashvinjeet S. Bedi, “Health Ministry detects five 'generations' of Covid-19 cases linked to tabligh cluster.” TheStar.com.my. The Star. Accessed March 31, 2020. https://www.thestar.com.my/news/nation/2020/03/27/health-ministry-detects-five-039generations039-of-covid-19-cases-linked-to-tabligh-cluster

[8] “5,084 in tabligh cluster yet to be tested for Covid-19.” FreeMalaysiaToday.com. Free Malaysia Today. Accessed March 31, 2020. https://www.freemalaysiatoday.com/category/nation/2020/03/28/5084-in-tabligh-cluster-yet-to-be-tested-for-covid-19/

[9] “Interim Clinical Guidance for Management of Patients with Confirmed Coronavirus Disease (COVID-19).” CDC.gov. Centers for Disease Control and Prevention. Accessed April 2, 2020. https://www.cdc.gov/coronavirus/2019-ncov/hcp/clinical-guidance-management-patients.html

[10] See e.g. “New coronavirus found in Japan evacuees who initially tested negative.” StraitsTimes.com. The Straits Times. Accessed March 31, 2020. https://www.straitstimes.com/asia/east-asia/new-coronavirus-found-in-japan-evacuees-who-initially-tested-negative

[11] See e.g. “Australians From Cruise Ship Test Positive for Coronavirus After Testing Negative in Japan.” VOANews.com. Voice of America. Accessed March 31, 2020. https://www.voanews.com/science-health/coronavirus-outbreak/australians-cruise-ship-test-positive-coronavirus-after-testing

[12] Carolyn Y. Johnson, “A ‘negative’ coronavirus test result doesn’t always mean you aren’t infected.” WashingtonPost.com. The Washington Post. Accessed March 31, 2020. https://www.washingtonpost.com/science/2020/03/26/negative-coronavirus-test-result-doesnt-always-mean-you-arent-infected/

[13] Regulation 3(1)(c) of the Prevention and Control of Infectious Diseases (Measures Within The Infected Local Areas) Regulations 2020

[14] Hiroshi Nishiura et al., “Estimation of the asymptomatic ratio of novel coronavirus infections (COVID-19).” IJIDOnline.com. International Journal of Infectious Diseases. Accessed March 31, 2020. https://www.ijidonline.com/article/S1201-9712(20)30139-9/fulltext

[15] See e.g. Denise Chow and Emmanuelle Saliba, “Italy has a world-class health system. The coronavirus has pushed it to the breaking point.” NBCnews.com. NBC News. Accessed March 31, 2020. https://www.nbcnews.com/health/health-news/italy-has-world-class-health-system-coronavirus-has-pushed-it-n1162786

[16] See e.g. Graham Keeley, “Doctors in Spain ‘totally overwhelmed’ as hospitals reach coronavirus breaking point amid soaring death toll.” Independent.co.uk. Independent. Accessed March 31, 2020. https://www.independent.co.uk/news/world/europe/coronavirus-spain-death-cases-hospitals-doctors-a9430026.html

[17] Nectar Gan, “China to lift lockdown on Wuhan, ground zero of coronavirus pandemic.” Edition.cnn.com. CNN International. Accessed March 31, 2020. https://edition.cnn.com/2020/03/24/asia/coronavirus-wuhan-lockdown-lifted-intl-hnk/index.html

[18] Emily Feng and Amy Cheng, “Mystery In Wuhan: Recovered Coronavirus Patients Test Negative ... Then Positive.” NPR.org. National Public Radio. Accessed March 31, 2020. https://www.npr.org/sections/goatsandsoda/2020/03/27/822407626/mystery-in-wuhan-recovered-coronavirus-patients-test-negative-then-positive: “From March 18-22, the Chinese city of Wuhan reported no new cases of the virus through domestic transmission — that is, infection passed on from one person to another”; see also “Beijing tightens quarantine rules for overseas travellers as China reports two-fold increase in new coronavirus cases.” StraitsTimes.com. The Straits Times. Accessed March 31, 2020. https://www.straitstimes.com/asia/east-asia/mainland-chinas-new-coronavirus-infections-up-by-two-fold-to-78-cases: “... of China’s four new locally transmitted infections on Monday, one was in Wuhan, the capital of central Hubei province. This follows five days of no new infections in the city, the epicentre of the outbreak in China.”

[19] See e.g. “Wuhan reopens after two-month lockdown.” BangkokPost.com. Bangkok Post. Accessed March 31, 2020. https://www.bangkokpost.com/world/1888260/wuhan-reopens-after-two-month-lockdown: “Liu Dongru, of the Hubei Health Commission, said that although parts of Wuhan had been reclassified as “low-risk” areas, work to control the virus needed to continue.

“Zero reported cases does not equal zero risk,” he said.”