Despite the fact that a strict lockdown in place due to Covid-19 pandemic, the Government on 4th May 2020 announced a relaxed lockdown with specific SOP aka Conditional Movement Control Order (CMCO) in place so that businesses that have been badly infected by this Covid-19 pandemic can get back on their feet. Infographic source: Bernama.
Current Situation in Malaysia
On 10th May 2020, the Government announced the extension of this flexible lockdown by another 4 weeks to 9th June 2020. However interestingly even before the CMCO was announced, I noticed that most of the restaurants and stalls have been opened, people have started to move around due to the decrease in police roadblocks and in my neighbourhood, stubborn residents have started to jog & walk as nothing have happened.
After 56 days locked down at home except for the occasional sprint to the hypermarket for essential groceries, I am back to the office for work whilst reserving some days for working from home. It was a new normal even at workplace with heavy precautions like social distancing (which meant no more meetings), spread out of the employees sitting place, constant temperature before entering the premise and maintain personal hygiene all times.
The Covid-19 outbreak situation in Malaysia has also improved with the fatality rate standing at 1.63% whilst the recovery rate to 80.90%. To date, there are still 1,213 active cases pending recovery. Comparing with others in the region, Indonesia has 12,495 active cases with 1,191 deaths making a fatality rate of 6.61% with 24.01% recovery rate whilst Singapore has 18,486 active cases with 22 deaths making a fatality rate of 0.08% with 34.70% recovery rate.
Big Data Simulation
On 30th April 2020, epidemiologist Michael Osterholm of the University of Minnesota and his colleagues published an analysis titled COVID-19: The CIDRAP Viewpoint which looks at 3 three possible futures of the COVID-19 pandemic based on past pandemics infections and also big data simulation.
Scenario 1 – Peaks & Valleys
Image source: Stat
The first wave of COVID-19 in spring 2020 is followed by a series of repetitive smaller waves that occur through the summer and then consistently over a 1- to 2-year period, gradually diminishing sometime in 2021.
The occurrence of these waves may vary geographically and may depend on what mitigation measures are in place and how they are eased.
Depending on the height of the wave peaks, this scenario could require periodic reinstitution and subsequent relaxation of mitigation measures over the next 1 to 2 years.
And when local outbreaks occur anyway, those measures will become stricter, even if only through voluntary measures. Many workers, frightened by a local flare-up, will telecommute if they can. People will again shun public transit, even taxis and ride apps. They will postpone scheduled surgeries and doctor visits, especially as telemedicine takes hold.
And then the outbreak will dissipate again, thanks to such measures. Many people will take that as a signal that it is safe to let down their guard. Social distancing will be less strict. The next wave will hit … over and over until so many people have been infected, or a vaccine succeeds, to produce herd immunity.
Scenario 2 – Fall Peak
Image source: Stat
The first wave of COVID-19 in spring 2020 is followed by a larger wave in the fall or winter of 2020 and one or smaller subsequent waves in 2021.
This pattern will require the reinstitution of mitigation measures in the fall in an attempt to drive down the spread of infection and prevent healthcare systems from being overwhelmed.
This pattern is similar to what was seen with the 1918-19 pandemic (CDC 2018). During that pandemic, a small wave began in March 1918 and subsided during the summer months. A much larger peak then occurred in the fall of 1918.
A third peak occurred during the winter and spring of 1919; that wave subsided in the summer of 1919, signalling the end of the pandemic. The 1957-58 pandemic followed a similar pattern, with a smaller spring wave followed by a much larger fall wave (Saunders-Hastings 2016).
Successive smaller waves continued to occur for several years (Miller 2009). The 2009-10 pandemic also followed a pattern of a spring wave followed by a larger fall wave (Saunders-Hastings 2016).
In this scenario, rather than reappearing throughout the year as the crests and troughs of the first scenario, Covid-19 would return with more ferocity in the late summer and fall and then dissipate, settling into a small but near-constant number of cases.
The precipitous, and lasting, fall-off would have two causes. First, so many people would be infected in the moderate first wave (now) and the gargantuan second wave (peaking around October) that the population might approach herd immunity. Second, the second wave, Osterholm said, “would absolutely take the health system down.”
An imminent or actual crash of the health care system, similar to what northern Italy experienced in March, would force national, state, and local officials to impose mitigation measures even stricter than those of the last six weeks, which — as happened in China from late January to early March — would mostly snuff out Covid-19.
Scenario 3 – Slow Burn
Image source: Stat
The first wave of COVID-19 in spring 2020 is followed by a “slow burn” of ongoing transmission and case occurrence but without a clear wave pattern.
Again, this pattern may vary somewhat geographically and may be influenced by the degree of mitigation measures in place in various areas. While this third pattern was not seen with past influenza pandemics, it remains a possibility for COVID-19.
This third scenario likely would not require the reinstitution of mitigation measures, although cases and deaths will continue to occur.
The waves keep coming because the size of the outbreaks that follow the current one is smaller than in the monster-wave second scenario. It, therefore, takes longer for population immunity to build up. Local outbreaks occur, worse in some places than others due to, among things, different capacity to conduct widespread, regular testing and contact-tracing.
No past influenza pandemic has ever followed this pattern. There are two reasons Covid-19 might, however.
One is biological: Coronaviruses, as shown by the four endemic ones, are frighteningly adept at continuing to circulate and never disappearing (the SARS coronavirus in the early 2000s was an exception).
The other is sociological: There are real questions about society’s capacity to withstand another economic shutdown, let alone repeated ones. In the future, those policies, at least in some cities and states, may well be less stringent, and therefore less effective at controlling outbreaks, than those imposed this spring.
That’s why future outbreaks in this scenario keep coming, with durations and caseloads comparable to the current one.
Progress of Vaccine
Malaysian Health Ministry is expecting that it will take about 12-18 months before we can see any usable Covid-19 vaccine in Malaysia. That means sometime in June 2021 and that too if it can pass the human clinical trials and government approvals. Meantime, recovery from Covid-19 needs to be done using a combination of various existing drugs. Infographic source: Forbes
As of 8th May 2020, the following progress on Covid-19 vaccines was reported:-
At least 120 vaccine projects are in various stages of development since China shared the genetic sequence of Sars-CoV-2, which causes Covid-19, with the World Health Organization (WHO) on January 12, 2020.
Of these, seven have entered human trials to test the safety and efficacy of the vaccine on healthy volunteers, according to WHO. Another 82 are in pre-clinical animal trial phases, and at least two have been found to protect monkeys from infection.
Johnson & Johnson, which was singled out by Trump as an example of vaccine success, said last month that it will be ready to produce 600 million to 900 million doses of its potential vaccine by April 2021 if human trials set to begin in September go as planned.
Pfizer and the German company, BioNTech, said if their human trials are successful, they can produce millions of doses by the end of 2020.
And on the various types of vaccines being developed, it is reported that there at least eight vaccine types that rely on different viruses or viral parts are being developed:-
Virus vaccines using weakened or inactivated virus
At least seven teams are developing vaccines using the Sars-CoV-2 virus in a weakened or inactivated form, such as those against measles and polio. Sinovac Biotech in Beijing is testing an inactivated form of Sars-CoV-2 in humans.
Around 20 projects are using coronavirus genetic material (DNA or RNA) to prompt an immune response. The nucleic acid is inserted into human cells, which then churn out copies of the virus protein. Most coronavirus vaccines encode the virus’s spike protein.
RNA- and DNA-based vaccines are safe and easy to develop: to produce them involves making genetic material only, not the virus. But they are unproven: no licensed vaccines use this technology
A weakened virus, such as measles or adenovirus, is genetically engineered to produce coronavirus proteins in the body without causing disease. There are two types of weakened viruses, those that can still replicate within cells, and those that cannot, because key genes have been disabled.
Coronavirus proteins, of fragments of proteins or protein shells, that mimic the coronavirus’s outer coat, are injected directly into the body. Protein subunits: Twenty-eight teams are working on vaccines with viral protein subunits, with most of them focusing on the virus’s spike protein or a key part of it called the receptor-binding domain.
Virus-like particles: Empty virus shells mimic the coronavirus structure, but aren’t infectious because they lack genetic material. Five teams are working on ‘virus-like particle’ vaccines, which can trigger a strong immune response but can be difficult to manufacture.
Moving Further In Malaysia
In Malaysia, presently we have 2 types of lockdown already in place – Enhanced Movement Control Order (EMCO) and now Controlled Movement Control Order (CMCO). CMCO is now scheduled to end on 9th June 2020.
Certainly when the Covid-19 pandemic was first made officially by WHO, the first target of any countries’ health authorities has been to contain the infection so that it does not overwhelm the health system as to how it happened in Italy in March 2020. It is called flattening the curve and it was not meant to be used as an indicator to say that there is no more new infection.
In Malaysia, the peak of active Covid-19 cases was back on 5th April 2020 with 2,596 cases and the curve has been reducing since then. On a daily basis, the number of new infection is lower than the number of recovered cases. However we still have on average 50 new cases on a daily basis and due to the EMCO and CMCO in place, we did not get any major reported clusters. Recent reported new clusters are rather isolated and manageable.
However, the controlled number will only be maintained if everyone embraces the new normal lifestyle which covers social distancing, wearing a mask and maintains personal hygiene. The target is to be under Scenario 1 where there will be some small, localised outbreaks that will be easily contained and isolated. Some form of localised lockdown will need to be imposed to ensure complete testing and recovery.
The worst-case scenario would be Scenario 2 where the second Covid-19 infection wave is even worse compared to the original infection wave and this time it overwhelms the health system – bringing in more new infection cases than what the hospitals can cope. There is a real danger that this scenario to happen in Malaysia considering even during the earlier lockdown, we had people openly ignoring the rules and being fined.
As at 26th April 2020, more than 21,000 individuals were caught breaching the lockdown. Further once most businesses are opened and everyone is back to their life before the lockdown, there will be some who will embrace the new normal.
Until an effective Covid-19 vaccine is in place, there is no doubt that the new normal will be the norm. Covid-19 is a pandemic that is not going to go away so soon and it is just one of the major pandemic that we are encountering in the near future.