Malaysia must be ready to confront an epidemic
THE Coronavirus Disease 2019 (Covid-19) that originated in Wuhan of China is indeed a tragedy of epic proportions. As of February 19, more than 75,000 people have been infected, resulting in more than 2,000 deaths. In comparison, severe acute respiratory syndrome (SARS) that broke out in 2003 infected 8,000 people and claimed 800 lives.
The first Covid-19 patient was traced to a person in Wuhan on December 1. A month later, on January 2, Wuhan hospital officials reported that 41 patients were ill with a new type of pneumonia, of which 27 had direct exposure to a local seafood market. At that point in time, it was also reported that initial lab tests and clinical data found no apparent human-to-human transmission; therefore, activities in the city of Wuhan could progress as normal. On January 20, Dr Zhong Nanshan, the respected epidemiologist who discovered SARS held a press conference to announce that there were Covid-19 patients in Guangzhou who had not been to Wuhan. This offered proof that local human-to-human transmission of the virus was possible. The public announcement by Zhong catalysed a strong response from the Chinese government to combat the rapidly expanding epidemic. The measures included sending thousands of medical personnel to infected areas, building new hospitals in Wuhan and closing all modes of transport in and out of the city. Fifteen other cities in Hubei province were also locked down, effectively quarantining 60 million people in their homes to contain the virus from spreading.
Current research now predicts that epidemics of the scale of Covid-19 are likely to occur again and spread widely at any single time to be pandemic. Furthermore, future epidemics could originate at anywhere in the world, and Malaysia is not immune to such a risk. Hence, we should carefully evaluate the events of the Covid-19 experience and capture the lessons learnt, so that in the unfortunate event that Malaysia is confronted with an epidemic of the scale of Covid-19 in the future, we are ready to respond effectively.
The Covid-19 epidemic has laid bare that the current social, economic and political structure worldwide is very fragile and vulnerable to inevitable future diseases and disasters of similar proportions. To reduce the risks of future disasters, including pandemics, the Sendai Framework for Disaster Risks Reduction (SF-DRR) 2015–2030 was developed. It provides the concept and practice for disaster risks reduction (DRR) through systematic and scientific efforts to analyse the causal factors of disasters and to reduce their impacts by enhancing the resilience of society. Resilience of a society is the capacity to adapt in order to maintain an acceptable level of social functioning and economic structure during and immediately after a disaster. This capability is determined by the degree to which the social system can organise itself to optimise the capacity for learning from past disasters. Learning from past disasters is critical for enhancing future protection and for improving future DRR measures.
Transparent and knowledge-driven modus operandi
Firstly, early detection of the epidemic and effective DRR measures are critical in quickly overcoming an epidemic with minimal loss of life. As can be seen in the Covid-19 experience, the negative impact of an infectious disease significantly depends on how quickly the disease is detected and how effective are the DRR measures taken. In the city of Wuhan, the epicentre of this outbreak, more than 44,000 infections and more than 1,400 deaths have been reported, as of February 19. This phenomenon can be explained via the bifurcation theory that governs how an infectious disease system undergoes regime shift from an endemic situation to a catastrophic epidemic. Infection transmission dynamics is governed by complex and nonlinear interactions among many components such as virus properties, physical contact rates and community education, awareness and social behaviour. Early detection and effective control measures implemented quickly will help to sharply cut down human-human contact rates. This has the desired result of significantly reducing the infection basic reproduction number (R0) that controls the transmission dynamics. Early detection and implementation of DRR measures will sharply reduce R0 to below 1.0, thereby preventing the spread of the disease. Furthermore, this will also sharply reduce the initial number of infected and infective individuals. The combined impact is that the disease will die down quickly resulting in only minimal number of infected and infective individuals. Late detection and ineffective DRR measures will vastly increase R0 and increase the initial numbers of infected and infective individuals. The undesirable consequence is to push the transmission dynamics to cross a threshold, permitting the systems to bifurcate from an endemic situation to a catastrophic pandemic. The bifurcation of complex ecological systems has been widely studied and reported in the literature. Learning from this pool of knowledge gained from ecological system dynamics is critical in epidemic control. Early detection and effective DRR measures are critical factors in controlling an epidemic and in preventing it from progressing to a pandemic.
As time is of the essence in effectively controlling epidemics, authorities must prepare crisis standard operating procedures and have trained personnel ready before the crisis. This is so that when the epidemic hits, the proper responses can be mounted quickly. In addition, it is essential that national jurisdictions maintain freedom of speech to ensure that early signals of an emerging epidemic can be reported from the population as soon as possible. Regulation to mitigate the risks and concerns of fake news are legitimate, however they should be addressed ex-post, by prosecuting the irresponsible perpetrators after the respective experts have proven their news to be fake. Excessive censorship will delay prompt action and miss the opportunity to control the epidemics.
Second, an optimum response to an epidemic is a proportionate response that effectively combats the epidemic, while simultaneously preserves basic human rights, minimises damage to the economy and ensures equity in public healthcare as much as possible. For example, a very dangerous virus like Ebola with a fatality rate of 50% should be handled with utmost caution in order to save lives. Hence, containment measures that are draconian, even at the expense of human rights and significant damage to the economy is justifiable. On the other hand, measures against H1N1 and annual seasonal flu, should not be too restrictive as the fatality rate is much lower at 0.1%. In the case of Covid-19, the mortality rate is between 0.16% to 4.9% varying from country to country, province to province, as well as from city to city, with Wuhan affected most severely with mortality rate of 4.9%, according to the National Health Commission of China. Therefore, a balanced response should be deployed that is effective but at the same time does not disproportionately deprive people of their basic human rights or cause disproportionate dysfunctions to the economy and societal development.
A proportionate response to an epidemic also necessitates a structured escalation and de-escalation process because the severity of an epidemic rises and falls throughout its lifecycle. When the epidemic rises towards its peak, stricter containment measures are necessary. However, when the epidemic begins to subside and infections begin to consistently decline, de-escalation in the containment process should be considered. Loosening of travel restrictions or relaxation of strict isolation policies would allow society and life to return to normal in a timely manner. In this regard, Singapore’s Disease Outbreak Response System Condition (DORSCON) system which categorises the severity of a disease outbreak according to 4 levels of severity, Green, Yellow, Orange and Red, then prescribes proportionate responses tailored to each level of severity, is a good model to study and potentially adopt.
International cooperation so no one is left behind
Thirdly, international cooperation is essential in effective epidemic management. In a globalised and interconnected community, huge challenges can only be solved through international collaboration as expertise and experiences are diffused across the world. Therefore, global efforts should go beyond developing a vaccine for Covid-19 currently being undertaken by teams in the US, Europe and Australia to include coordination of health care resources. Another area of epidemic management which requires international cooperation is humanitarian response. In this current episode, international response should have been implemented to enable passengers on the two cruise ships (Diamond Princess and MS Westerdam) stranded out in the open sea to quickly be placed under quarantine at several selected and prepared countries to reduce the stresses put on a particular country. SF-DRR mandates that no one is left behind. These passengers should be allowed to return home as soon as possible, without exposing others to the risk of the contagion. Having to deal with 3,000 passengers from 40 countries, international coordination is essential so that passengers can be safely tested for the virus, humanly quarantined and properly treated as necessary before they can return to their home countries. The burden of international collaboration in assisting the stranded cruise ships’ passengers should be distributed fairly among nations, in order to reduce public fears for any particular country.
As an epidemic recognises no man-made borders, international partnerships and collaborations are instrumental in coordinating a holistic set of DRR strategies to effectively counter the epidemic across borders. This has been explicitly acknowledged by SF-DRR. International collaboration also advances knowledge, innovation and education to build a culture of health, safety and resilience at all levels. Therefore, in southeast Asia, Asean needs to identify environmental, social, economic, cultural, and political factors and processes that require urgent transformation so that practical solutions for national and regional DRR measures can be developed, and equitable, resilient and sustainable development through research, education and community engagement can be fostered. Malaysia as one of the founding members of Asean can play a leadership and positive role in this regard.
To date, Malaysia has reported 22 cases of Covid-19 with no fatalities. Malaysia’s Health Ministry has done well in putting in place monitoring mechanisms at our border entry points, in preparing our hospitals to be effective in testing suspected cases and in treating patients with utmost care and respect. Its leadership has been transparent in communicating to the public the latest situation of the contagion in Malaysia. Nonetheless, Malaysia needs to be cognisant that it has been impacted relatively mildly by Covid-19 as Malaysia did not receive many visitors from Hubei province. Therefore, Malaysia cannot be complacent. Research shows that another Covid-19 scale epidemic could occur anywhere in the world in the near future. We need to be ready to effectively respond to such future shocks. The Malaysian Government, in particular the National Agency for Disaster Management needs to be vigilant in drawing up disaster management plans and in training our personnel now. Should the unexpected occur, there will be no time to prepare.