JANUARY 14 — I think the MOH needs to stop making wild predictions of flattening the curve and the weeks of MCO it would require to achieve so [1]. It has fallen short on several occasions since the onset of the third wave. And it is most unfortunate that the blame is more often than not heaped on the rakyat as failing to comply with the SOP.
To begin with, for posterity sake, the MOH was gung ho about being fully prepared for come what may in PRN Sabah [2]. It was the very failure of the MOH to uphold the SOP that the third deadly wave was unleashed in Sabah with the spillover into Semenanjung, and which they have been unable to mitigate since, despite their earlier assertion that the CMCO was the best way to reduce R naught [3].
And true to the idiom, the devil’s in the details, the rakyat who are now mercilessly trapped with the #StayHome Emergency Ordinance, has every right to know the exact plans of the MOH to get them out of this mess which the government and MOH self-inflicted.
The key element in the blueprint of action to mitigate this Covid-19 national emergency, must surely be a well-executed Find, Test, Trace, Isolate and Support (FTTIS) system recommended by the WHO, which has fallen terribly short in its national implementation.
Until and unless this back to basics of population infection control is efficiently and effectively operationalised, the nation will continue to relapse into a vicious cycle of unending MCOs.
The FTTIS system Finds and Tests hotspots of Covid-19 outbreaks. Rapid Isolation of cases and quarantine of close contacts through Tracing is extremely critical. Isolation will only work if the rakyat, especially the B40, receive Support during the MCO period with food security and financial Support [4].
The government through its relevant ministries and agencies must provide this social security net and support to this new policy of home isolation to ensures its success. Otherwise, the rakyat will fail to comply with home isolation, in order to search for and put food on the table and scour for basic home essentials. The government already have in place Low Risk Isolation Centres for households who are unable to effectively isolate at home.
Clinical support is also vital for monitoring the health of cases and contacts who are undergoing home isolation in the community.
Data on the following Key Performance Indicators (KPI) can reassure the rakyat that the FTTIS system in place is capable of detecting and isolating suspected cases and contacts within 48 hours.
1. What percentage of tests results are returned within 24 hours?
2. What percentage of positive cases are informed within 24 hours?
3. What percentage of people with a positive test are successfully contacted within 24h to find contacts?
4. What percentage of named contacts are contacted within the next 24 hours?
5. What percentage of contacts comply with isolation?
6. What percentage of cases/contacts in isolation/quarantine require/request support receive them?
7. If a symptomatic person has a negative test, but the symptoms persist, how quickly can they get another test?
A most recent circular from the MOH, dated 13 January 2021, titled Surat Pekeliling Ketua Pengarah Malaysia Bil. 2/2021 at para 4.3 notes:
4.3 Bilangan sampel yang diambil adalah bergantung saiz kohort iaitu bilangan keseluruhan individu yang terdedah dalam kluster tersebut:
a) sekiaranya kurang dari 50 orang, memadai diambil 20 sampel; dan
b) sekiranya melebehi 50 orang, memadai 30 sampel atau 10 per cent mengikut mana yang rendah
We fail to understand the rationale of this reduced testing strategy. We should be ramping up testing to achieve a positive rate of less that the WHO 5 per cent benchmark of pandemic control. As at 12 Jan 2021 our positive rate was 8.2 per cent.
Imagine if you only screened 10 per cent of the cluster, and all returned as negative whilst the positive cases were all in the 90 per cent you failed to screen, this would be totally disastrous. This new strategy is against good public health science and is against all norms of targeted mass screening. Besides the MOH must remove its thinking from absolute numbers and shift to incidence rates which is a basic Public Health metric. This MOH mindset and strategy of Do Less-Test Less-Less Positives-Less Daily Cases is the very anti-thesis of a holistic FTTSI programme and must be rectified.
Granular data on the success (or otherwise) of each component of FTTIS should be shared, in real time, with all key stakeholders in order to support decision-making and response at both the national and state level.
Digital applications, leveraging on data science and machine learning will most certainly enhance the process of contact tracing.
Since super-spreader events and persons are a major cause of Covid-19 transmissions (80 per cent of all infections arise from just 20 per cent of those infected), backward contact tracing should be combined with standard forward contact tracing to achieve optimal effectiveness.
Rapid and seamless integration between MySejahtera and Selangkah datasets is essential to provide high quality information to the community to build trust and engagement, whilst complying with the Personal Data Protection Act 2010.
The 2 Apps should be further developed to support people to adhere to isolation and enable them to report symptoms daily and receive appropriate treatment and medical intervention should their condition deteriorate.
Strategic risk communications is vital to help the rakyat to understand the purpose of FTTIS. Apart from information to assess infection risk following proximity to an index case, recognise early signs and symptoms, they should be directed as to the when, how and where to get tested, and how to obtain financial and social support, and request for transfer to a low risk isolation centre if isolation at home is inappropriate.
With the imminent availability of Covid-19 vaccines, apart from wide scale awareness programmes to inform and empower the rakyat with the benefits and safety of being immunised, counter fake vaccine news, the appropriate logistics should be put into place to facilitate mass immunisation.
The FTTIS strategy could be utilised to spearhead the immunisation programme, FTTIS-Immunisation, FTTISI, as a holistic package of healthcare services to flatten the Epidemic Curve and a return to near-normalcy.
The MOH is the implementer of the re-strategised FTTISI blueprint of action. There is a dire need of a national task force as a system of oversight to ensure that every aspect of the hexavalent system is working synchronously, efficiently and effectively during the period of the MCO and post-MCO towards virtually zero Covid-19 or a baseline endemicity which is acceptable for peaceful co-existence with the coronavirus.
The Task Force must be empowered with the authority to continually evaluate the FTTISI programme, ensure that the KPIs are met and if the deliverables are not forthcoming, to trouble shoot the problems and provide the pertinent solutions. They should be accountable directly to the cabinet and the Prime Minister, unlike the presently internal audit of the MOH by the MOH, which has not served the nation well.
National lockdowns and emergency ordinances are blunt tools of pandemic management [5]. They are imprecise and damaging tools used only as a final resort to prevent surges of infections in order to protect the healthcare capacity. They severely disrupt virtually all aspects of our human existence, physical, mental, socio-political and economical. In the second quarter of 2020, the nation’s GDP plunged by 17.1 per cent, the worst in our history, consequent upon the national MCO, to contain the Covid-19 pandemic [6].
The FTTISI strategy is only fully effective if it is able to isolate the maximum numbers of Covid-19 cases and their contacts from the wider community. The three Critical Success Factors are namely:
1. Leadership of the national pandemic management plan that is competent and transparent which builds trust and ownership in the FTTISI programme
2. Clarity of risk communication which informs and empowers the rakyat as to the importance of FTTISI and what they are expected to do.
3. Food security, financial and other social support so that rakyat can do what is being asked of them.
Notes:
3. https://www.nst.com.my/news/nation/2020/11/639702/cmco-best-way-reduce-r-naught
4. http://ilo.org/wcmsp5/groups/public/ — -asia/ — -ro-bangkok/documents/publication/wcms_751600.pdf
5. https://www.malaysiakini.com/columns/546082
6. https://www.thesundaily.my/business/gdp-plunges-by-record-171-in-q2-LF3474094
* Dr Musa Mohd Nordin is a paediatrician and Asst. Prof Mohammad Farhan bin Rusli a public health physician.
** This is the personal opinion of the writer or publication and does not necessarily represent the views of Malay Mail.
