The Movement Control Order – Are we turning the tide?

This is an opportune time to assess the impact of the Movement Control Order (MCO) on the Covid 19 epidemic as we are now at the end of the first MCO period announced on 16/3/2020 by the Prime Minister. The Graph below which charts the number of new cases of Covid 19 over the past 9 days suggests that the number of new Covid cases per day has plateaued. This is quite different from the trajectory of the epidemic in Spain and in the USA where the numbers of new cases are still increasing. The graph suggests that for the period between 16/3 and 23/3/20, each new case was, on the average, passing the infection to one other person before being diagnosed and isolated – a transmission ratio of 1.0. This is better than the 2.6 figure transmission ratio quoted by epidemiologists. (Epidemiologists have worked out that in the absence of control measures, each Covid 19 patient will, on the average, infect 2.6 other persons before being diagnosed and isolated – a transmission ratio of 2.6. This results in the doubling of the number of new cases every 4 days and the generation of an exponential rate of increase in Covid 19 cases.)

Series One : New Diagnoses of Covid 19 in Malaysia

But it is not sufficient to bring the transmission rate down to 1.0. We need to bring it down further if we want to reduce the number of new cases. If the average transmission rate could be pushed down to say, 0.8, this would result in the reduction of new cases by 20% every six days and the impact will be cumulative – 0.8 at day six, 0.64 at day 12, 0.54 at day 18, 0.44 at day 24 and 0.35 at day 30 (of the number of new cases on day zero). If we attain the 0.8 transmission ratio we will reduce our new cases to about 53 per day in a month’s time (150 x 0.35).

The MCO strategy alone may not be enough to accomplish this. The MCO keeps people confined in their homes and guards against the transmission of the infection to 10, 20 or more people attending the same mass function. The MCO has played a major role in bringing out transmission rate down to 1.0. We now need to figure out how to push the transmission rate even lower. It appears that the National Security Council hasn’t thought this through properly yet For their recent statements are focused on tightening the restrictions and using more punitive measures to enforce this. This is making life more difficult for ordinary citizens. You do not need to do this.

The NSC has to change tack and identify more smart and effective measures to bring the transmission rate down. A good place to start is to ask how people still manage to get infected despite there being a MCO. There are, I think 2 main ways people are now getting infected. One is from contaminated surfaces in shops, groceries, banks and markets that they visit to obtain essentials. The other is from an infected family member who resides in the same house. We need to address both of these to be able to drive down the transmission ratio to below 1.0. The following additional measures should be seriously considered by the NSC –

  1. Masks for everyone who ventures out of the house

Some of the people now catching the Covid bug are probably getting their hands contaminated with the virus when they go out to the bank, the groceries or the wet market. The problem is that, when a person gets infected with Covid, he or she might not realize that he/she is infected for the first few days. He/She might feel quite normal but may have already started shedding the virus especially in the later part of the incubation period. When such a person goes out for groceries or the market he/she can contaminate surfaces without realizing it and this might lead to the infection of other people using the same facilities.

The incidence of this can be reduced quite markedly by requiring everyone to wear a mask when they enter a bank, a grocery or a supermarket. The purpose of the mask in this instance is not to protect the wearer, but to trap the infected droplets he/she might be emitting – it is to protect others. As the purpose is to prevent droplet contamination of surfaces, a simple homemade reusable cloth mask will suffice. That would be much cheaper and will not exacerbate the shortage of the proper N95 masks that the health personnel require. These cloth masks can be cleaned by soaking in warm soapy water for 30 minutes before washing and reusing it. We believe it will be a game changer.

  1. Better quarantine of contacts

At present all the household contacts of a confirmed Covid case are required to self-quarantine – that means they are supposed to stay in for 14 days, strictly. But is this being done adequately? Proper self quarantine requires that each person of that household has his/her own room with an attached bathroom. Most homes in Malaysia do not have such facilities. So there is a high risk that the contacts will infect each other. The index case for the family might have just passed the infection to one person in the household. But because of the cramped living area, eventually most household members turn positive.

Is the MOH and the NSC looking into this? Quite a number of hostels were identified for the purpose of quarantining contacts. Are they being used? Perhaps we need to leave the mother and the children below the age of 18 in their own home and provide them provisions regularly. But the other members of the household should be required to move to the quarantine hostels for the 14 day long quarantine period and their meals and other basic needs be provided by the government.

The MOH and the NSC should continuously assess the adequacy of the quarantine effort. How many identified contacts are there for each diagnosed case? How many of them are under a proper quarantine? What is the rate of infection among contacts? Are some States or Districts performing more poorly on these scores? The available data has to be broken up to district level and utilized to spot the “outliers” so that remedial action can be taken. If necessary more staff should be deployed for this important effort of quarantining the contacts effectively so that we cut further transmission of the virus.

  1. Earlier testing of symptomatic cases.

The PCR-RNA test that detects Covid RNA should be done on all those who have any 2 out of the following 5 symptoms – fever, cough, sore throat, body aches and loss of smell. Unfortunately, even now, government hospitals outpatient departments withhold this test from patients who despite having these symptoms have no history of travel to certain countries or contact with a known Covid cluster because there is a shortage of the reagents in the government sector. This leads to delays in the diagnosis and isolation of positive cases. But at the same time, doing the swab test seems to have become a bit of a fad for the well-heeled who do not have any symptoms – and it is being promoted by some private hospitals, some of which have organized drive-ins (and charge around RM 550 per person). This is a waste of a scarce resource, and should be discouraged. People should be told that testing negative for Covid today in no way protects one from getting Covid tomorrow or the day after. Early testing has an important role to play, but it must be driven by clinical criteria, and not by the ability to pay or by commercial considerations. The government must put more money into doing the PCR-RNA tests for all patients with suspicious symptoms. Earlier diagnosis will enable earlier isolation and lessen the chances of virus transmission.

  1. Winning the trust of the migrant worker population.

As argued in the above sections, the key to controlling the Covid epidemic is a combination of early diagnosis, efficient contact tracing and effective quarantining. Given the fact that two thirds of the approximately six million migrant workers in our country do not have documents and they live in fear of the authorities, can the above control measures be implemented for them. If we fail to get their support and cooperation the migrant workers community might well turn out to be the “Archilles Heel” of Malaysia’s Covid Control Programme.

This is a serious issue, but it appears that the NSC is reluctant to address it holistically. There is a MOH circular dated 29th January 2020 says that all migrant workers will be treated for free if they are diagnosed as Covid cases. But the same circular says that if they are not Covid cases they would need to pay the charges as specified in the Garis Panduan Perlaksanaan Caj Baru (2014). These charges are several times higher than fees paid by Malaysian citizens. Delay in seeking treatment because of the fear of the high charges will lead to rapid transmission of Covid 19 once it spreads to the migrant worker population (as it is likely to do sometime in the future).
The People’s Health Forum submitted a Memorandum to the National Security Council on 19th March 2020 which proposed 2 main measures to handle the issue of Covid control among the migrant worker population –

a/ A suspension of the 2014 Fee Schedule for Migrants, and

b/ A moratorium on arrest and imprisonment for immigration offences
for the next one year.

These two initiatives together with approaching the migrant worker population through their informal associations and NGOs might help our health department gain their trust and cooperation with regards to self-referral, testing, contact tracing and quarantining. Incidentally quarantining will require their placement is quarantine hostels as they generally live in extremely cramped conditions. If we fail to develop this trust, there is a danger of explosive spread through this stratum of our society necessitating yet another (economically debilitating) MCO in the future. It would be in our “enlightened self-interest” to implement the two measures suggested by the People’s Health Forum. We hope the NSC will take this issue seriously. It would be extremely silly to be “penny wise but pound foolish”.

So to answer the question posed in the title of this article – yes, we have markedly slowed the transmission of Covid 19 in Malaysia. And the MOH, the NCS as well as the general public should be given the credit for this. But we need to do more – the rate of transmission must be brought down to 0.8 or less so that the number of new cases start going down. And it is important that this be done as soon as possible for the MCO is painful to many. We need to restart our economy so that goods and services can be produced for our people, and families have the opportunity to work and earn the money necessary to meet their needs.

Families going hungry.

The PSM has one final request for the National Security Council – you need to urgently address the fact that some families have run out of food. The daily rated workers, the rubber smallholders, the micro-business owners in the Pasar Malams and casual workers are facing problems as they cannot work, and they didn’t have much savings to start with. PSM branches throughout the country are being approached by families asking where they can get help. It is good that the Economic Stimulus Package announced by the Prime Minister on the 27th of March 2020 includes a cash transfer of RM 1600 to 4 million poor families, but that’s only to be rolled out in late April. That is far too late for the families which are facing a cash crunch now. Can the NSC look into this urgently as quite a large number of families are affected? Surely the particulars of the BRIM and BSH recipients are already in the government database. Why can’t the cash transfer be initiated in the first week of April itself? It would make a great difference to these families!

We are half way through the MCO period, and we are making some progress. Let’s stay the course, cooperate with the authorities, stay indoors as much as possible but also reach out to families in need of food and other basic supplies. There are many challenges ahead – reviving the economy in the midst of a global recession is going to be another huge problem after we emerge from the MCO. But nothing is insurmountable if we address it on the basis of solidarity and science! Hang in there!

Dr.Jeyakumar Devaraj
PSM Chairperson

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