COVID 19

COVID-19 pandemic is the greatest communicable disease outbreak to have hit Malaysia since the 1918 Spanish Flu which killed 34,644 people or 1% of the population of the then British Malaya. In 1999, the Nipah virus outbreak killed 105 Malaysians, while the SARS outbreak of 2003 claimed only 2 lives. The ongoing COVID-19 pandemic has so far claimed over 100 Malaysian lives. There were two waves of the COVID-19 cases in Malaysia. First wave of 22 cases occurred from January 25 to February 15 with no death and full recovery of all cases. The ongoing second wave, which commenced on February 27, presented cases in several clusters, the biggest of which was the Sri Petaling Tabligh cluster with an infection rate of 6.5%, and making up 47% of all cases in Malaysia. Subsequently, other clusters appeared from local mass gatherings and imported cases of Malaysians returning from overseas. Healthcare workers carry high risks of infection due to the daily exposure and management of COVID-19 in the hospitals. However, 70% of them were infected through community transmission and not while handling patients. In vulnerable groups, the incidence of COVID-19 cases was highest among the age group 55 to 64 years. In terms of fatalities, 63% were reported to be aged above 60 years, and 81% had chronic comorbidities such as diabetes, hypertension, and heart diseases. The predominant COVID-19 strain in Malaysia is strain B, which is found exclusively in East Asia. However, strain A, which is mostly found in the USA and Australia, and strain C in Europe were also present. To contain the epidemic, Malaysia implemented a Movement Control Order (MCO) beginning on March 18 in 4 phases over 2 months, ending on May 12. In terms of economic impacts, Malaysia lost RM2.4 billion a day during the MCO period, with an accumulated loss of RM63 billion up to the end of April. Since May 4, Malaysia has relaxed the MCO and opened up its economic sector to relieve its economic burden. Currently, the best approach to achieving herd immunity to COVID-19 is through vaccination rather than by acquiring it naturally. There are at least two candidate vaccines which have reached the final stage of human clinical trials. Malaysia's COVID-19 case fatality rate is lower than what it is globally; this is due to the successful implementation of early preparedness and planning, the public health and hospital system, comprehensive contact tracing, active case detection, and a strict enhanced MCO.

Keywords: coronavirus, pandemic, movement control order, Malaysia, COVID-19

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Introduction

Pandemics of the 20–21st century

Throughout the 20th century, three influenza pandemics occurred over several decades; the most severe was the “Spanish Flu” (caused by an A(H1N1) virus), estimated to have resulted in 20–50 million deaths in 1918–1919. Milder pandemics occurred subsequently in 1957–1958 (the “Asian Flu” caused by an A(H2N2) virus) and in 1968 (the “Hong Kong Flu” caused by an A(H3N2) virus), which were estimated to have caused 1–4 million deaths each.

An influenza pandemic caused by the A(H1N1) virus erupted in the 21st century (2009–2010). For the first time, a pandemic vaccine was developed, produced, and deployed in multiple countries during the first year of the pandemic. The H1N1 pandemic was however milder than the ones before, estimated to cause between 100,000 and 400,000 deaths globally in its first year (1).

History of Epidemics in Malaysia

Newspapers in Malaya had as early as September 1918 carried reports of the raging influenza pandemic in South Asia. The only details of the spread of the epidemic were substantially documented from the medical report of the British North Borneo from June to November. The account indicates most possibly the transmission of the influenza virus from the maritime and land routes ferrying passengers and migrant workers from the South China Sea to the rest of the hinterland. This was the Spanish Flu brought in from Europe which resulted in 34,644 deaths among the 3,584,761 population then, giving a fatality rate of almost 1% (2).

Over a period of 8 months in 1999, the Nipah virus infected 265 Malaysians and killed 105. Malaysia's response was delayed because it was initially misidentified as Japanese encephalitis. The SARS outbreak of 2003, which infected 8,098 and killed 774 people globally, claimed only two lives in Malaysia. The present COVID-19 was brought into Malaysia by Chinese tourists from Wuhan via Singapore and Malaysian citizens who traveled to high COVID-19–infected countries such as Italy and Indonesia.

Origin of COVID-19

Pneumonia of unknown etiology was detected in Wuhan City, Hubei Province of China on December 31, 2019, whereby, the WHO China Country Office was informed. From December 31, 2019 through January 3, 2020, a total of 44 cases of pneumonia of unknown etiology were reported in China, of which the causal agent was not identified.

On January 7, 2020, the Chinese authorities identified a new type of coronavirus. China shared the genetic sequence of the novel coronavirus for countries to use in developing specific diagnostic kits on January 12, 2020. WHO later received further detailed information from the National Health Commission China on January 11–12, 2020 that the outbreak was associated with exposures in a seafood market in Wuhan City.

On January 13, 2020, the Ministry of Public Health, Thailand reported the first imported case of laboratory-confirmed novel coronavirus case (2019-nCoV) from Wuhan, Hubei Province, China. On January 15, 2020, the Ministry of Health, Labor and Welfare, Japan reported an imported 2019-nCoV from Wuhan.

As of January 20, 2020, a total of 282 confirmed cases of 2019-nCoV have been reported in China (278 cases), Thailand (2 cases), Japan (1 case), and Korea (1 case). Cases in Thailand, Japan, and Korea were exported from Wuhan City, China. Among the 278 confirmed cases in China, 258 cases were reported from Hubei Province, 14 from Guangdong Province, 5 from Beijing Municipality, and 1 from Shanghai Municipality.

On January 30, 2020, WHO declared the outbreak of COVID-19 a public health emergency of international concern. WHO's greatest concern was the potential for the virus to spread to countries with weaker health systems which will be ill-prepared to deal with the outbreak (3).

A modeling study published in The Lancet on January 31 estimated that, on average, every infected individual is infecting 2.68 additional individuals (4). The specifics of how the virus is transmitted from person to person have also yet to be defined. It is still unknown whether the virus can be spread by the fecal–oral route, for example. The disease pathogenesis is shrouded in mystery. How does the virus replicate in different sites, and how does that relate to the severity of disease?

It was also uncertain how long patients remain infectious. Thus, it is difficult to decide on the period of isolation. There is also the possibility that the virus is mutating into transmissible forms. Older patients with comorbidities seem to be most at risk of developing severe disease as a result of infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Information from China stated that case fatality is around 2%.

Transmission of COVID-19

COVID-19 is largely spread via droplets in the air and is a respiratory illness. These droplets are typically expelled when an infected person coughs or sneezes. They become increasingly less infectious once symptoms develop, so that a person's viral load declines steadily. However, infected persons keep shedding the virus after they recover from COVID-19 for around 2 weeks in both their saliva and stools. Infected persons with mild or no symptom can have a very high viral load in their upper respiratory tracts. They can shed the virus through spitting, touching their mouths, or noses or possibly through talking. SARS-CoV-2 has also been found to persist for days on surfaces (5).

Fever, dry cough, and tiredness are the most commonly reported symptoms, and in mild cases people may get just a runny nose or a sore throat. In the most severe cases, infected persons experience breathing difficulty, and ultimately organ failure may develop. Some cases are fatal. The authorities in China have placed the Wuhan population under quarantine or lockdown, and stopped trains and flights out of the city. They have suspended certain long-distance bus routes, including those that depart or arrive in Beijing. On March 11, WHO announced the outbreak to be a pandemic, which means that multiple countries are seeing sustained transmission between people, causing disease or death (Figure 1) (6).