There is light at the end of the tunnel! Our vaccination program has accelerated to more than 400,000 shots per day, and already around 5 million Malaysians have received both shots and another 5 million have taken the first. Credit should be given to the Ministries that have procured and are delivering these vaccines to our population. They are doing a good job in ramping up the vaccination exercise. This is a good sign for the nation – it means that we have the institutional capacity to design and deliver effective programs when the Cabinet commits to these programs.
However, the end of the tunnel – the attainment of 80% vaccination cover for our population – is still several months away. (80% of 38 million is 30.4 million – the virus does not discern between citizens and the 6 million migrant workers in the country.) There is therefore the very real possibility that we will witness more surges of Covid infections in places outside the Klang Valley in the next few months as we have not achieved the vaccine coverage level we need to prevent explosive growth of clusters. The genie is out of the bottle, and our current MCOs are not going to be able to put it back in! It will take a much stricter and prolonged Movement Control Order (MCO) to achieve that, but that would impact adversely on the economy and the livelihoods of many Malaysians. We do not have the social capital to embark on such a course. People are already quite irate!
The high number of “sporadic” cases is a clear indication that the virus is circulating in the community. As bringing down the daily infection rate to 2 digit figures is not within our reach, the general population must continue to strictly observe physical distancing, double masking and avoidance of crowds for a few more months until we get 30.4 million people vaccinated. Interstate travel should be avoided. This is certainly not the time to let our guard down. The attempt by the MOH to paint a rosy picture by breaking down newly diagnosed cases by clinical categories is poorly conceived. A person who is category 1 on the day of diagnosis could quite easily deteriorate to category 4 by the end of that week and to category 5 by midway through the second week of symptomatic illness! It would be more beneficial to the public if the MOH were to include a breakdown by category of the cohort of patients diagnosed 3 weeks prior as part of the statistics released daily. That would give the truer extent of the problem and motivate people to observe the safety precautions. My assessment is that about 20% of cases go into category 4 and require oxygen, 4% progress to category 5 and about 1.5% die.
So, as the spectre of future spikes is still high, all our States need to prepare for the very real possibility that they might suddenly be beset by a surge in cases.
The Phases of Covid 19 Infection
To prepare for the proper care of Covid cases in the event of a surge, we first need to understand how the Covid 19 infection unfolds in infected persons and how best to curtail morbidity and deaths. There are 2 distinct phases in the first 3 weeks of Covid 19 infection – the first phase is when the virus multiplies in the body causing fever, headache, cough, body aches and several other symptoms. This “viraemic” phase lasts for about 5 days before the patient’s immune system produces the antibodies and the killer lymphocytes that attack and smother the virus particles thus blocking the virus from infecting new cells. In about 80% of the cases, the illness ends here, and the patient begins to recover.
However in about 20% of the cases, the patient goes into the second phase – his/her immune system goes into over-drive (the “cytokine storm”) and this overreaction causes damage to the patients vital organs – lungs, heart, kidneys and brain. We are still not too sure why this happens, but the effects of immunological “exuberance” can be worse than the initial damage by the virus itself. The overactive immune system also disrupts the normal clotting mechanism in the patient resulting in multiple small clots forming in many organs causing further damage to these organs.
Doctors treating Covid cases have found that early treatment can limit the damage cause by the immunological phase of a Covid infection. Steroids can dampen down the “cytokine storm” and low molecular weight heparin can reduce the tendency to form clots in the blood vessels. However these interventions have to be given before multiple organs have been damaged. You have got to catch the “cytokine storm” early and nip it in the bud.
Early intervention will reduce the need for ICU admission. Waiting for the patient to develop oxygen desaturation before initiating steroids and heparin is rather late. For best results we need to look for the early signs of the cytokine storm and abnormal clotting – and these can be found via blood tests. The cytokine storm will consume cytokines (obviously) – and the levels of a group of substances in the blood – the complements – will drop. Similarly disseminated clotting all over the place will consume platelets and clotting factors such as prothrombin and result in elevated D-dimers (a breakdown product arising from clots within the blood stream).
You might wonder why not start the steroids and the heparin the moment Covid is diagnosed. We can’t, because we need the immune system to bring the viraemic phase under control. And also in 80% of cases, the body knows when to stop. So our strategy should be to identify as early as possible the 20% of cases who go on to the second phase – the immunological phase of the illness.
The immunological over-reaction usually kicks in at about one week after the start of the viraemic phase. But we cannot use the date of onset of symptoms to determine when the viraemic phase started. Some people have very minor symptoms during the viraemic phase and then develop devastating complication in the subsequent immunological phase. This, I think is the reason behind the spate of brought-in-dead cases. Their immunological over-reaction caused a life threatening complication eg heart attack, or pulmonary embolism although their initial illness was relatively mild. The incidence of this phenomenon seems to be higher with the current variants in the population.
We have to arrange for the management of any future surge in Covid 19 infections based on this understanding of the natural history of the illness, and the fact that when a surge occurs, admitting every case to hospital is not an option as very soon we would be out of hospital beds.
The Action Plan
First of all, we need to build capacity for out-patient screening for Covid. This should be by a drive through method as that will reduce exposure of other people to suspected Covid cases. People who suspect they have Covid infection should call their nearest Covid 19 Assessment Centre (CAC) to get an appointment to come for a drive-through nasal swab test or a saliva antigen test. If they do not have their own transport, then the CAC should send a mobile lab team to collect the sample. I would think that the rapid antigen test that looks for specific Covid antigens is good enough to make the diagnosis in this pandemic setting. The RNA PCR test (which has a mechanism to multiply the viral RNA) is more sensitive, but takes far longer (24 to 48 hours compared to 4 to 6 hours for the antigen test) for the result to be known.
Ideally, all diagnosed cases should have a blood test done to assess complement levels, platelet counts, prothrombin time as well as D-dimer levels. As we do not want these patients to come to hospital for their tests, we need to send properly attired mobile units that can go to their homes, draw their blood as well as take nasal swabs for household contacts, and teach them how to take their own pulse rate. Personnel Protective Equipment is of crucial importance here, because this is the phase when Covid patients are emitting the most virus. By the time Covid patients develop immunological overreaction and get admitted to hospital, their viral load is much lower and they are far less likely to transmit the infection to others.
Those who are asymptomatic or minimally symptomatic can be allowed to quarantine at home together with their household contacts. Theoretically it would be ideal to quarantine all the household contacts separately but that would require a lot of resources, and it is uncertain how helpful such a practice would be in reducing intra-household transmission. It appears that Covid 19 patients start emitting the virus about 24 hours before the onset of symptoms. And it usually takes another 24 hours or more after the onset of symptoms before the diagnosis is confirmed by tests. This means that household contacts are exposed to the virus for more than 48 hours prior to any attempt to isolate the index case in that household. Is isolating family members separately worth the effort? MOH data comparing the rate of household transmission in patients who were removed to quarantine centres with that of patients asked to quarantine at home would be useful in deciding this issue. Can we get some epidemiologists in our universities to look through MOH data to quickly throw some light on this issue? We should be guided by the empirical data for this. My gut feeling is that separate isolation of household contacts will not reduce transmission rates to household members significantly. Perhaps we should still offer older family members who are not fully vaccinated the option of a single-room hotel stay for a week.
The Covid 19 Assessment Centres (CAC) should follow up on the home quarantining patients every day via phone calls. The CACs should set up teams including general practitioners, retired doctors and nurses who would each be assigned 10 to 20 patients to follow up every day via phone calls. The caller should screen for danger signals – shortness of breath, heart rate of over 110/min, confusion and/or persistence of symptoms for more than a week. The caller should also ask regarding the situation of other family members in the household and whether any essential provisions are needed, for example long-term medicines that family members are already on. There must a simple format to report back to the coordinator of the home quarantine program at the CAC. There should also be a mechanism set up where essential provisions are delivered to the homes of the quarantining patients if required – perhaps Rela or even the army can be involved in this. If the patient being monitored at home develops any of the danger signs he/she needs to be brought to the next level of care for assessment.
The next level of care would be the make-shift hospitals that have been set up in convention halls, schools and stadiums. More such venues should be readied in other States. Here clinical examination, pulse oximetry, blood tests (including those mentioned above) and if warranted, a Chest Xray would help ascertain whether they have pneumonia (would make them category 3). The National TB Control program had a number of mobile X-ray units mounted in specially designed ambulances. We should quickly procure a few of these to service the field hospitals. Category 3 cases can be managed as inpatients in the makeshift hospital.
If the patient has a low oxygen saturation (hence qualifying for category 4) or any laboratory evidence of immunological over-reaction, he/she will require immediate commencement of treatment at the field hospital itself – oxygen therapy, steroids and low molecular weight heparin as indicated, while admission to a hospital is arranged.
Being prepared for possible surges
I think it would not be an over-reaction on the part of the authorities to make the preparations that I have sketched out above. A lot of effort would be required to ramp up the capacity of the CACs. More staff would need to be hired to handle each of its various responsibilities as described above. Current SOPs will have to be upgraded to meet the new responsibilities of the CACs. The aim is to move a large part of Covid management out of the Hospitals so that the hospitals can concentrate on the more ill patients. This strategy also is aimed at catching the deteriorating patients early so that their slide to a more critical stage of the illness can be arrested.
We need to develop these capacities now itself so that if a surge were to happen, we have the ability to handle it. Our case fatality rate (CFR) for Covid 19 has soared from 0.38% in 2020 to about 1.8% currently. CFR refers to the percentage of diagnosed Covid cases who die. Part of the reason for the higher CFR now could be that the current strains are more vicious. But the fact that our hospitals are overloaded and treatment to dampen the cytokine storm is not started soon enough is also a factor.
Let’s take all the steps we can to reduce ICU admissions and to bring the Case Fatality Rate down to lower than where it was in 2020. The government has shown that it can implement programmes effectively if it sets its mind to it – witness the vaccination program. Let’s hope some of the above suggestions are acted upon – they would save us a lot of pain!
Dr. Jeyakumar Devaraj
Parti Sosialis Malaysia