These past weeks have been tough for all of us, especially as it is hard for us to see an end to the coronavirus (Covid-19) outbreak. Many of us wish we had a reset button that could make this all disappear. We wish that we could wake up from this nightmare and realise that it was all just a dream.
However, this extremely difficult reality is here with us to stay. We are actually just beginning with this outbreak, in the early stages of this epidemic. We have to start thinking of exit strategies, that is, what we are going to do after the movement control order (MCO) or partial lockdown has been lifted.
Some people have the false expectation that we will be able to go back to our previous lives. We can only return to our old ways if one of three things happens. Firstly, the virus dies out due to effective lockdowns all over the world or tones down to become like the seasonal influenza. Secondly, we manage to find a miracle cure that can treat large numbers of people and reduce the severity of the disease. And thirdly, we rapidly develop a highly effective vaccine that can be mass produced and distribute it to large volumes of the population to give us immunity. All these prospects are highly unlikely, hence it would be fooling yourself to think this will end. There is no immediate return to the old ways.
We cannot continue indefinitely with some form of lockdown. If the epidemic continues, we will reach an impasse, a time when the lockdown will become more than we can tolerate. We are speaking not just of economic loss but of the poor dying from starvation, many dying from other diseases (collateral damage) and some dying from despair (suicide).
We are living in a new reality, what we call the “post-coronavirus reality”, and we have to learn how to change, how we can adapt and survive this reality. We would like to share some preliminary ideas and thoughts on exit strategies from a lockdown.
Exit strategy 1: Give up and give in
The first option, a very painful one, is to stop all that we’re doing and go back to the way we used to live. This, in fact, is “giving up” and allowing the epidemic to spread widely. What percentage of the population needs to be infected before normality returns? Possibly up to 60%-80%. The capacity of the health service to treat people will be overrun, and the death toll will be enormous, but it may be relatively shorter-lived.
The death volume from this strategy will depend on how explosive the epidemic will be. In the space of six to nine months, we can expect hundreds of thousands of deaths (assuming 2%-5% mortality and 60% of the population infected with limited ICU care). This death volume does not include collateral deaths from other conditions that could not get ICU beds or had treatment delays (head injuries, strokes, septicaemic patients, cancer, etc). It also does not take into account that 15% of those infected with Covid-19 will require oxygen, which we may not be able to provide for all. This will lead to more deaths. It also ignores that some survivors will have chronic lung damage. After the outbreak is over, the virus will probably become endemic like the influenza virus and cause intermittent deaths at a much slower rate.
Some believe that Wuhan is gradually returning to normality, and that we will also be able to do the same. Remember that the estimated number infected in Wuhan is 500,000, out of a population of about 11 million people. Hence, the percentage infected is only about 4.5%, hardly enough to achieve herd immunity. Wuhan still has the capacity to have large outbreaks and they are far from achieving a normal life.
Exit strategy 2: Segregate old people and children/adults with chronic conditions
This strategy, a dramatic one, will require an intensive, coordinated effort. It also comes with its own risks. It involves us segregating persons above the age of 60 and children/adults with comorbid conditions (that is, chronic conditions that put them at risk of dying from the coronavirus) from the rest of the population. Once you are over 60, the mortality rate is ~10%. This rises to 30% by the time you are 80. The remainder of the population, the younger and fit ones, will continue to live as before and allow the coronavirus to spread widely so as to develop herd immunity. Once most are infected (check with antibody test studies), we reunite the country.
But what an undertaking. It would involve moving three to four million Malaysians. It would also have to be done at many sites all over the country and require carers and logistics for the very old and very young. It would require a united and responsible (obedient) population led by an efficient government. In short, it would require something close to a miracle.
But there are serious risks. When we transport these “high-risk” persons together, we risk the virus spreading among them. If we do not house them appropriately in apartments and rooms, we again risk the virus spreading by bringing them together. To offer an example, we were informed that the federal territories ministry is planning to round up the homeless and place them all in a stadium. This kind of move, if done poorly, could see disaster as the homeless are a vulnerable population. If one person or helper is infected, the coronavirus will spread widely when we transport them together or put them together in a large stadium (close proximity and sharing bathrooms). Only a hostel or hotel is the right place (the UK has done this for their homeless).
There are also unresolved issues. Will immunity post-infection and recovery last long term or can we be re-infected? How many deaths will we experience among adults aged 20-60 if we implement this exit strategy? A very conservative estimate is about 50,000 deaths. It seems we have a “no-win” situation on our hands.
Exit strategy 3: A more realistic exit strategy
This is not an easy option and will require strict discipline from every person in the country for it to work. It will require us to cooperate and work together like we have never done before. Not as individuals but as a responsible family, a nation of sisters and brothers. We have to prepare to put in place all the steps required before the MCO or partial lockdown is lifted.
In effect, this strategy is to “allow” the virus to spread at a controlled rate while we get back to some normality in life. It would be ideal to eradicate it but currently, that seems unlikely. This exit strategy makes the assumption that we can control the current outbreak at a reasonable level. However, we must expect that Covid-19 cases will rebound episodically after we control each “wave” of outbreak. This will continue for some time until it gradually fades.
Allow us to outline how this exit strategy would look. These are merely broad brush strokes; an enormous amount of thinking, planning and change in behaviour will be required. Once the MCO or partial lockdown is relaxed, we will have to do the following:
1. Continue to maintain strict physical (social) distancing as a long-term lifestyle
We have to consider physical (social) distancing the new norm. All social gatherings will have to be drastically revised. All sports events, weddings, funerals, birthday parties, etc should be streamed live and not attended, apart from participants or immediate family (not even relatives). All work places, colleges, universities and schools will have to rethink working and teaching methods, seating arrangements, toilet and pantries/canteens, meetings, etc. Everywhere, we will have to prevent crowds, limit physical contact and practise physical (social) distancing at all times outside our home. This will include transportation, makan shops, supermarkets, playgrounds/parks, recreational areas, religious gatherings, hotels, etc. Whatever can be done online should be moved there – meetings, shopping, socialising, training, entertainment, etc. We will have to change many, many things, even guidelines for lift usage and space-out movement on escalators.
In this strategy, we want to echo the truth that Jonathan Smith, an infectious disease epidemiologist, articulates: “You should perceive your entire family to function as a single individual unit: if one person puts themselves at risk, everyone in the unit is at risk.” Once one family member is infected, all are at high risk of infection. So we will have to work as family units.
2. Cleaning hands and surfaces must be normative
We have all heard the message loud and clear and will need to keep following it at all times: wash or sanitise your hands after every exposure, don’t ever touch your face outside the house, and disinfect surfaces frequently. As a society, our level of hygiene and cleanliness will have to surpass even the best country in the world. We will have to be proactive in cleaning surfaces after we come into contact with them. Carrying alcohol-based hand sanitiser will have to be normative and routine for months, if not years. We will have to train all our cleaners for proper wipe-downs of all contact surfaces.
3. Using masks must become commonplace
At any one time, on any given day, a small proportion of the population will be having a mild respiratory illness. It must become our custom to wear a mask if we have a fever, running nose or cough. Preferably, we should stay at home if we are unwell. Employers and teaching institutions should be sensitive to ill persons and offer (paid) home leave liberally. Carrying spare masks should become routine and we should consider using them when in confined space with others who are not immediate family, for example when travelling together. We need to seriously consider all the evidence that is emerging that the routine, widespread use of masks (even homemade cloth masks), as in South Korea, Japan and China, helps decrease the spread of Covid-19 by a significant extent. We may want to adopt this strategy.
4. Develop rapid-response coronavirus teams (‘precision quarantine’)
We will need, in every state, emergency coronavirus squads that can rapidly spring into action when a small “outbreak” of coronavirus is suspected. They will have to do aggressive contact tracing and implement effective home quarantine for those suspected to be ill (what some are calling “precision quarantine”). For this to happen, we will need rapid testing capacity (results in one to two hours, if not faster). Only the significantly ill should be transferred to hospital and even that, to limited designated locations so as to allow the regular hospitals to carry on with routine work. Those who are mildly ill should be offered home oxygen therapy.
5. Availability of mass testing capability
Even as we relax the partial lockdown measures, we must be aware that the coronavirus will start to spread again. We need the availability of mass testing that will allow us to identify individuals while they are still asymptomatic and allow for early self-isolation. We should especially provide and prioritise mass testing for healthcare professionals in general practice and out-patient clinics, teachers, service individuals providing deliveries, working in supermarkets, and other frequent public contact locations.
6. Use technology wisely to track contacts
The current interview-based contact tracing is tedious. We must put in place a national handphone-based contact tracing system like Singapore has done. While we need to protect citizens’ privacy, we also need to speed up contact tracing and inform the public that they are at risk and should either get tested or self-isolate. It is best not to develop our own system but to adopt one from Singapore, South Korea or other nations that have successfully implemented it. This is not the time to develop and test a system that may fail.
7. All travellers into the country should be screened
As we lift or relax travel restrictions, we run the risk of introducing fresh infections into the country. We may need to test all those entering the country, and this can only be done with rapid testing capacity. Those who travel frequently (e.g. daily to Singapore and back) will be a major issue. For some who were infected and have recovered (presuming re-infection does not happen), a test showing antibodies (recovered from the infection) could be documented on a “coronavirus test result card” that everyone carries.
8. Waiting for vaccines to arrive and provide immunity to the population
This may be the longer-term strategy. However, even the best-case scenario suggests that the earliest we will see a viable vaccine is 18-24 months, most likely later. If the vaccine works and immunity lasts, we still have many issues. How to get supply when the whole world will want such a vaccine? It may take years to reach us if the methodology is not shared and we lack the technology to produce it. Once available locally, we will also have to prioritise who gets it first and not allow VIPs and those who can pay to hog it. We need to give it to older persons, those with chronic diseases, healthcare professionals and service providers (e.g. cashiers at supermarkets).
We have not covered other measures required to enable a meaningful exit strategy, to return to a normal life. Other measures include growing public health services that have been neglected for decades, boosting our medical facilities to increase intensive care beds, economic support and stimulus for the nation, dealing with recession and job loss, enhancing safety nets and social support especially for vulnerable individuals and communities, etc.
This article was written with the intention of beginning a dialogue as a nation. There are many intelligent and capable individuals and groups in our country who can offer useful ideas and suggestions for a meaningful exit strategy. We need to harness everyone and listen to diverse opinions. There may be other options and we need to use our collective creativity and resources to come up with the best ones.
We need to accept the reality that Covid-19 may be around for a long time and that we may see many cycles of outbreaks. The bottom line is that every Malaysian must start preparing and thinking now. We have to cooperate with each other and work as we said, like a family. There can be no place for sectarian differences, whether religious, political or ethnic. This virus has the ability to traumatise every single family and our entire nation. Only together can we overcome it.
Dr Amar-Singh HSS and Dr Lim Swee Im are FMT readers.
The views expressed are those of the authors and do not necessarily reflect those of FMT.
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