Steer cautiously towards endemicity

Steer cautiously towards endemicity

SINGAPORE’S high daily Covid-19 cases post-easing of restrictions in August (as part of its strategy of “living with the virus”, given a high percentage of vaccinated population) is a likely similar trajectory for Malaysia.

As Malaysia seeks a transition into the endemic phase and people increase interactions, we may see cases rising again down the road (i.e. a fourth wave). However, Malaysia’s more diverse vaccine types and larger population, larger time gap between people who received the jab earlier and later in the year, and a seriously lax behaviour when it comes to adhering to standard operating procedures (SOP) are factors that would likely magnify the severity of the impact.

So long as vaccines work as they should and no new variants emerge with significant mutations that could evade vaccine-induced immunity and give it deadlier characteristics, we should see a situation identical to Singapore, where most cases are either asymptomatic or of low severity categories.

CNN reported Singapore’s health ministry as quoting that 98.2% of Singapore’s 31,057 infected individuals over the past 28 days (since Oct 2) were either asymptomatic or down with mild symptoms.

However, if Malaysians ignore SOP and take vaccination for granted, the increased transmission may contribute to the emergence of immunity-evading variants.

Observations on how people mingle at public parks, restaurants and other public places indicate poor adherence to physical distance and masking. These places have been seen as crowded, with few people wearing double masks, and fewer wearing face shields. We can only wonder if people pay attention to good hygiene practices such as washing hands.

As our respiratory tract continues to act as a reservoir for virus transmission, antigenic drifts (changes in the structure of antibody targets such as parts of the virus spike) are a real possibility with increased viral replications, consequently undermining vaccination effectiveness, putting us back to square one. This is a lose-lose situation for everyone, and we may not have the economic and mental strength to go through another round of lockdowns.

Well before these things happen, we can still be carriers and expose the virus to vulnerable groups who are more likely to suffer greater disease severity if infected. Therefore, we have to remain vigilant at all times.

Health Minister Khairy Jamaluddin’s call for people to conduct self-test before visiting family members is good. The reason for the consideration of further lowering the price ceiling on self-test kits is so that people are able to conduct tests regularly.

Thus, several things are of utmost importance in moving forward. Firstly, we need to enhance genomic monitoring to monitor and detect variants, and boost immunological studies to monitor vaccine-induced immunity from various vaccine brands (potential waning of immunity from those receiving jabs earlier), as well as natural immunity.

It has been reported that over 12,000 people that have recovered from Covid-19 are being monitored to study long Covid. So, perhaps the same cohort can be used to study natural immunity.

Combining local and global data, correlating between demographic profiles, vaccine types, antibody levels and protection against different variants will allow better visibility on the virological and immunological status of the nation, and guide related decisions such as boosters.

Secondly, we need safe and effective treatments to prevent progression of disease severity, hospitalisations and deaths. In this regard, the reported procurement of Covid-19 pills could be a game changer. That said, we are still left with less novel options for the treatment of severe cases.

For those in severe categories (which should be a minority so long as variant-evasion of immunity is not present), we will need new treatments to supplement current clinical management practices.

According to the World Health Organisation guideline, this may include the use of certain monoclonal antibodies to treat high-risk patients with non-severe disease, and patients who have not mounted an antibody response and suffering from severe disease(s).

There are other potential treatments for severe Covid-19 such as anti-interleukins that the authorities should monitor. Even though these novel biologics are generally expensive and not in large supply, they should be considered for the relatively few people in severe categories.

The focus now should be studying rare cases of vulnerable groups that do not have protection from severe disease despite being fully vaccinated, and formulate strategies to
address this.

Self-management vs blanket restrictions

Although Singapore has opted to reimpose restrictions, which may include tighter crowd size limit and work-from-home instead of partial office capacity, Malaysia should try things differently and perhaps only embark on wide movement restrictions in the event of a surge in cases due
to new variants that can evade vaccine-induced immunity and cause severe symptoms.

In this case, we will need a hard stop on people’s mobility to stifle further transmissions and provide temporary breathing room to formulate strategies against the new threat.

In the absence of new immunity-evading and/or more lethal variants, self-management and personal movement restrictions should be the way forward. Any fears of exposure or early manifestation of symptoms should call for self-testing.

Positive self-test confirmed with RT-PCR must be reported through MySejahtera, and the person should impose self-quarantine.

Meanwhile, the Health Ministry can trace and alert potential close contacts to conduct self-test at home, and these people also should report their results. Those infected should be quarantined until a set period of time where symptoms must subside, at which they have to do another self-test
for confirmation.

If people can adhere to this, there should be no need for wide (e.g. interstate) movement restrictions. Thus, it is clear that authorities must embark on communication strategies to educate people on the proper usage of self-test kits, and make reporting mechanism easy, secure and trusted.

There must also be constant checks by the authorities to ensure the mass production of these home test kits meets strict standards, continuously updated to remain relevant and accurate. Accuracy, reliability and proper use of the self-test kits are absolutely essential for this strategy
to work.

With the empowerment of public and private clinics i.e. a decentralisation strategy, mechanisms of reported positive cases should be combined with the assignment of local clinics to monitor positive cases to prevent worsening of disease and cases of brought-in-dead.

Relatedly, the newly procured Covid-19 pills must be made widely available to these designated healthcare professionals to be prescribed to patients under their care.

If these antiviral pills work as they should and are proven safe in the long run, then many patients may avoid hospitalisations and many lives could be saved. In addition, pressure from public hospitals would also be alleviated.

Self-care and personal health responsibility go hand-in-hand and on this note EMIR Research applaud other steps adopted by Khairy such as calling for people to live healthier lives. This is a great start, but it should extend into policy changes that promote preventive care and better access to healthier lifestyle options.

Other strategies that have been mentioned by Khairy such as a mix-and-match strategy for booster jabs are all aligned with strategies proposed by EMIR Research. However, we call for cautious and stringent review of the booster as suggested earlier, utilising local data and global findings.

Additionally, in addition to genomic and immunological studies, there should be a study on potential virus transmission reservoirs in children and animals (paediatric and zoological reservoirs) as part of overall Covid-19 monitoring programme.

Ameen Kamal is the Head of Science & Technology at EMIR Research, an independent think tank focused on strategic policy recommendations based on rigorous research.

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