LETTER | Queries on quarantine and SOP

Dr Musa Mohd Nordin


LETTER | The government has sought to clarify SOPs around ministers' quarantine times, saying they would only need to quarantine for three days provided they strictly follow a “travel bubble itinerary.” Do you agree with this provision?

The ministers’ three-day quarantine period is based on political science. It is not premised on evidence-based science.

And we know only too well that when politics overrides the science of Covid we are headed for disaster as has happened in the US where Donald Trump’s pseudoscience has the US leading the world with 28 million cases and half a million deaths.

The incubation period for Covid-19, which is the time between exposure to the virus and the appearance of symptom is between five and six days, but can be as long as 14 days. The risk of transmission is extremely low (~1 percent) after 10 days with monitoring and testing in place. 

The US Centers for Disease Control and Prevention (CDC) notes that the shortest period for quarantine is seven days if one receives a negative test result. This is as practiced in France. Therefore, three days is not only insufficient, it is actually potentially dangerous.

With the presence of super-transmissible mutants of Covid-19, notably the UK B117 and South Africa’s B1351 and Brazil’s P1 mutants, it is extremely important that we maintain a strict border control to prevent importation of these strains.

If the minister returns from a foreign trip and is infected with one of these variants, and is allowed to roam free after three days, he will be spreading the mutant strain to the public and become a super-spreader. 

The SOP of 10-day quarantine must be practiced to ensure that the mutant strain is not allowed to escape into the community. The exemption order must be revoked. It threatens the national effort to curb Covid-19 and especially in preventing the entry of dangerous mutant strains into our country.

We need to very quickly immunise our population to achieve herd immunity and prevent the super spreader strains from incubating here as it has created havoc in more than 82 countries. 

On Tuesday, the government announced that restaurants may now allow dine-ins again. This sparked some mixed reactions online. While some welcomed the move, others expressed that our cases are still too high. Where do you stand on the latest relaxations of restrictions?

The guiding principles in this issue are related to the following; the more an individual interacts with others, the longer that interaction; the closer the distance and without masks, then the higher is the risk of Covid spread.

This dining in indoor spaces with inadequate ventilation has 18 times the risk of transmission than outdoors with good ventilation.

The lowest risk in the food and beverage business service limited to drive-through, delivery and take-outs. The highest risk is with on-site dining with indoor seating.

This risk can be further stratified according to the infectivity rate (IR) in any specific district or state. This utilises the metrics called IR by acute cases or incidence rate.

For example, Malacca, Sabah, Negeri Sembilan, Penang, Sarawak, Terengganu, Perak, Kelantan, Kedah, Pahang Perlis have an IR that is lower than the Malaysian average of 1.6 per 1,000. The risk of you getting Covid in theses states is less than 0.16 percent or one in 600 persons

However, the risk of you getting Covid is three times in KL, two times in Selangor, Putrajaya and 1.5 times in Labuan and Johor. Therefore it seems sensible to allow dining preferably outdoors, with SOPs in all states except these five.

In any case, surely decisions around what SOPs to implement must be based on data. And we haven’t really seen many clusters of Covid-19 cases among diners, but rather, most have been centered around workplaces. Do you have a clear sense of the yardstick the government is using to set SOPs?

Digital apps that utilise data science, AI and machine learning should be able to do the risk stratification and advise us whether it is wise or not to dine outdoors. In fact, not just for dining but most other living activities, for example:

  • Meeting friends and family
  • Going to work
  • Opening of schools and nurseries
  • What we can do in our leisure time
  • Shopping
  • Attending places of worship, funerals, weddings
  • And making travel plans

We are already one year into the pandemic. I think there is really no need for these daily press conference by the senior minister or the MOH.

It is very scary when the SOP shifts like a moving target virtually every other day

Instead, by using my handphone SELangkah or MySejahtera app, I should be able to access the following information daily

  • the risk of me getting Covid in my district or state, eg in Seremban or in NS
  • the trends of Covid cases in my area
  • it then me tells me what SOP I must follow
  • it tells me with one click on the Malaysia map the risk of getting Covid in other districts or states
  • so that I can decide whether to balik kampung or not for CNY
  • this information will empower me to do the right thing

One measure to assess whether we’re testing enough for Covid-19 is by looking at the share of tests that are positive. And Malaysia’s share of positive tests has been above the WHO recommended level of five percent (as of early February we’re about eight to nine percent). So why do you think there has been insufficient testing, as this measure suggests? Is the system just overwhelmed?

The WHO benchmark of positive rate is less than five percent, which means that the outbreak is well under control.

Malaysia’s positive rate since the onset of 3rd has hovered between six to nine percent. This is much higher than Thailand, South Korea, Taiwan, Singapore and New Zealand, countries which are doing very well in containing the pandemic

The MOH says that it will be doing double digits soon. This is a self-fulfilling MOH prophecy.

This is not much different from Trump’s Covid-Science. You do fewer tests you will get fewer cases. We are only doing about 50,000-60,000 tests per day. The MOH plans to ramp to 200,000 tests per day.

To meet the WHO benchmark of five percent, we expect to see five percent of 200,000, that is 10,000 cases per day. But we are only registering 3,000 to 4,000 cases per day. This means we are either under-testing, under-detecting or under-reporting.

The public health test of choice for surveillance is the Rapid Antigen Test RTK-Ag. The turn around time (TAT) is one hour – so you can immediately isolate and do contact tracing.

So we get a rapid response in our FTTIS (Find-Test-Trace-Isolate-Support) strategy. The MOH has a flawed obsession with PCR for public health Surveillance Testing.

It is not a size fits all for the PCR. The PCR is however the test of choice for confirmation and clinical diagnostic purposes in a hospital setting.

You have also highlighted that it’s perhaps not as useful to know the cumulative number of Covid-19 cases or deaths because it doesn’t give us an accurate illustration of how widespread it is. What metrics do you think the government should focus on instead to ensure clearer communication?

The daily cases count by the respective states does not paint a true picture of the pandemic. Of course, Selangor will register the most number of cases because:

  • there are more people in Selangor, 6.57 million exactly, about one in five persons actually live in Selangor.
  • it is the most industrialised state contributing 24 percent of Malaysia’s GDP.
  • most industries and construction sites are here.
  • there are one million migrant workers (MW) and another one million unregistered MW.
  • there are 100,000 refugees who live in the Klang Valley.
  • both the MW and refugees are epicentres of Covid outbreaks

The best way to illustrate the burden of Covid is through the use of incidence and prevalence rate.

Active cases per 1,000 population tell us the incidence rate of Covid, the likelihood of you getting Covid.

Cumulative cases per 1,000 population tell us the prevalence rate of Covid, the number of persons in any state having Covid at any one point in time.

Then you can compare apples and apples. This is Epidemiology 101.

In recent months, MOH has also allowed for some Covid patients to be quarantined at home. This has led to some concerns over the deaths of patients at home. How can this be avoided?

Category 1 and 2 cases, ie the asymptomatic and mild cases, can be isolated at home with clear SOP.

All Category 1 and 2 cases must register with SELangkah or MySejahtera, so that they can be assessed and provided with home kits.

The home kits include:

  • Face masks
  • Hand sanitisers
  • Info pamphlet
  • Food pack vouchers for B40, unemployed, and those doing day jobs
  • Saturation monitors including training and monitoring, reserved for high-risk patients

All high-risk positive case needs to be assessed to decide whether they need to be observed in the Low-Risk Centre or Covid hospitals.

In Selangor, all contacts of positive cases will be notified by the SELangkah App and they can be tested at STFO community mass screening or SELcare panel clinics (B40 are provided free testing vouchers). Others can get it at affordable prices, RM50-70 per test compared to RM150-280 at private centres.

CoSMoS is Covid Symptom Monitoring System. It is a home monitoring service for patients diagnosed with Covid-19.

CoSMoS allows healthcare providers to monitor your symptoms closely.

Over-the-phone consultation service is provided when your symptoms are getting worse.

DR MUSA MOHD NORDIN is a paediatrician and chairperson of the Federation of Islamic Medical Associations advisory council.

The views expressed here are those of the author/contributor and do not necessarily represent the views of Malaysiakini.