February 2022 Vol 2 No 12

Although your Editor, Jamari Mohtar, is concerned that daily cases of Covid-19 are on the rise in Malaysia, and a new threshold of more than 30,000 daily cases was recorded on February 23, people are saying that this is what endemicity is all about – learning to live with the virus. But what does endemicity really entail? Read on …

  • Those who thought so is focusing on the definition of endemic as co-existence with the virus per se, when the correct definition is co-existence with the virus without a staggering loss of lives, so that normalcy will be the order of the day.
  • The above article was written on Oct 31 last year when the death figure was 37. On Feb 22 this year, it was 43 deaths followed by 55 the next day.
  • The last time the daily death number was zero was on Dec 4, 2020.
  • So after more than three months since the article was written, the daily death figures have increased though still in the two digits. We have come a long way to this situation after going through much trial and error in combatting the scourge.
  • It is not only in Malaysia there was trial and error. This is because Covid-19 is a new animal since its appearance in late 2019 in China that has caught many governments operating in a context of radical uncertainty, being faced with difficult trade-offs given the health, economic and social challenges it raises.
  • Already there are two approaches in combatting the pandemic. One is the zero-Covid path with its emphasis on lockdown, border closure and strict preventative measures which were being implemented successfully by countries like China and New Zealand, among others.
  • The other approach is via the endemicity path whose proponents include Singapore, Malaysia and many European countries, which is based on the notion that the virus is here to stay for the long haul and so to achieve a zero transmission is almost impossible and we just have to learn and live with it.
  • But the endemicity approach is yet to see any success so far because it is still a process or a transition towards endemicity i.e. work in progress.
  • To some, endemicity is how normal life resumes. Some pundits and politicians would argue that we are actually, already at endemicity or at the very least, we should be acting as if we are. It is how a devastating pandemic virus ends up docile.
  • But endemicity promises exactly none of this. Really, the term to which we’ve pinned our post-pandemic hopes has so many definitions that it means almost nothing at all.
  • What lies ahead is still a big uncertain mess, which the word endemic does far more to obscure than to clarify.
  • According to a Harvard infectious-disease expert, Yonathan Grad, ‘this distinction between pandemic and endemic has been put forward as the checkered flag,” a clear line where restrictions disappear overnight, Covid-related anxieties are put to rest, and we are “done” with this crisis.
  • That’s not the case. And there are zero guarantees on how or when we’ll reach endemicity, or whether we’ll reach it at all.
  • Many are clueless on what endemicity is all about and hence, fail to distinguish between the process and the end result.
  • The endemicity approach is hinged on one basic premise – a truly endemic state is reached when the virus is circulating among us without being the threat that it is now and without a large number of hospitalizations.
  • So what does it mean when proponents of endemicity say “when the virus is circulating among us without being the threat that it is now”?
  • Obviously, it refers to the high rate of daily transmission that is now in the five digits in Malaysia.
  • But proponents of endemicity have never specified the digit of daily transmission that constitutes a non-threatening situation.
  • Given that in endemicity it is impossible to attain a zero transmission, so does a one-digit, two-digit, three-digit or four-digit daily infection constitutes a non-threatening situation?
  • This failure to specify has led to many saying that the daily infection number is not important, as what is important is that serious cases are below 1% of the total daily cases.
  • What if the daily infection number is in the six digits, as happened in many Europeans countries as early as last month? Assuming the daily case is 100,000 and 0.5% of this are serious cases that would mean 500 serious cases needing ICU beds, oxygen supplementation and ventilators.
  • Seeing that a hospital would normally have 1,000 beds, out of which about 300 to 500 are ICU beds, 500 serious cases are manageable only if the six digit daily case is a one-off event.
  • But as experienced in many countries, once the five or six-digit figure is hit, it will go on and on for at least a week or so, sometimes more, and those who were hospitalised will not be discharged for the next three to four days because these are serious cases we are talking about.
  • This will put a tremendous pressure on the healthcare system, resulting in poor care of the patients, which will have a knock-on effect in term of simultaneously raising the death rate and the transmission rate, even among the frontliners.
  • An important cornerstone of the endemicity approach is you cannot reach endemicity without the waves of transmission because there can be no natural immunity without infections.
  • High natural immunity (used to be called herd immunity) in the community can come about only when people are infected, say the proponents of endemicity.
  • The more infections there are (and people recover from their infection), the greater will be the natural immunity in the population. This is why you cannot reach endemicity without the waves of transmission.
  • With every wave of transmission, the natural immunity in the population also increases, making the population more resilient.
  • This looks like a very logical argument but its main weakness lies in assuming people who are infected will necessarily recover.
  • Some don’t and become a statistic in the daily death number, while others may regress from Category 1 to 2 or from 2 to 3 and so on.
  • The fact that in most countries during waves of transmission, the daily recovery number is always less than the daily infection number shows that this argument should be treated with a pinch of salt.
  • Moreover, it will only lead to an act of stupidity in wanting to get infected so that your natural immunity will increase.
  • There is, however, a merit in the argument that endemicity doesn’t mean an attempt to stop the transmission, as it aims only at reducing or slowing down the transmission to ensure the healthcare system is not overwhelmed so that every sick person can be cared for.
  • And this is also the reason why some restrictions are still in place, which means it is a process towards endemicity because when endemicity is reached, there shouldn’t be any restrictions.
  • So people should get it in their head that endemicity is a long process, and there is still a need presently to observe restrictions and its SOPs and be circumspect when you have to go out in the open.
  • This does not mean you cannot go out of your house. It is just a personal decision with responsibility i.e. you decide whether it is necessary to go out. If it is, by all means go! Just take the necessary precautions. Otherwise stay at home.
  • Recently, there is a debate on whether it is too early to open up the borders in light of the increasing number of daily cases recorded.
  • Closed borders will affect the economy, especially the supply chain industry and may strike a fatal blow to the tourism and aviation industry, which are huge revenue earners for any economy.
  • Taking into account that statistics in many countries show transmission of the virus via imported cases are relatively lower than community (local) transmission, there is a case for opening up the border.
  • The danger is always that the unsuspecting foreigners coming to our country as tourists, businessmen, government officials, exhibition and conference goers may be infected when they reach our shores.
  • From there, they can spread the virus through community transmission.
  • Imported cases also refer to locals who return to the country from abroad.
  • Hence, while the daily cases is on the rise and constitute a threat to the situation, opening of the borders must be done gradually and with some restrictions.
  • It is indeed not the time to do away with mandatory quarantine in opening up the borders. Even when endemicity is reached, mandatory quarantine is always a must for positive cases.
  • So it very disturbing and worrying for people to react with joy whenever the proposal of removing quarantine is mooted, including mandatory quarantine.
  • What can be done is gradually to remove quarantine by first reducing its duration. Quarantine used to be two weeks at the start of the pandemic.
  • Now it is five days for asymptomatic close contacts with booster jab, seven days for asymptomatic close contacts that are fully vaccinated and 10 days for the asymptomatic, unvaccinated close contacts.
  • This can be reduced further to three days, five days and seven days respectively once the threat of a rising daily cases has subsided.
  • During the early days of the pandemic, if you’re positive, you had to be quarantined for 14 days. Now, it’s seven days if you’re fully vaccinated and asymptomatic, and 10 days if you’re not fully vaccinated or unvaccinated and you’re symptomatic.
  • Moreover, even if you’re positive but as long as you’re asymptomatic (Category 1) or having mild symptoms (Category 2A) and are not in the high-risk category (i.e. below 60 years old and have no comorbidity), you’re allowed to be quarantined at home. 
  • A day will come when the threat of a rising daily cases has subsided, these quarantine period should be reduced further to lesser days than it is now, and a truly endemic stage will see all mandatory quarantine will be a home-based one that are limited to the positive cases only.
  • Malaysia is moving towards this direction when on Feb 24, Health Minister Khairy Jamaluddin announced individuals above the age of 18, who have taken their booster jab will no longer be required to undergo a Home Surveillance Order (HSO) if they don’t show any symptoms of the disease after coming into close contact with a Covid-19 positive case. This will take effect on March 1.
  • Also due to the fact that imported cases are relatively lower than cases via community transmission, we can start now by allowing all foreigners visiting the country including locals returning from abroad not to be subjected to mandatory or home quarantine if they are tested negative on arrival.
  • All these moves to reduce the quarantine period, and making it easier for home quarantine are to be seen as the process towards endemicity.
  • When endemicity is reached, even close contacts should not be quarantined as long as they are negative and don’t show any symptoms.
  • There are really only two ways of doing things with regards to opening the border.
  • One is you can really move very fast towards the true state of endemicity in as short a time as possible by removing all restrictions, open all borders, or you can have a controlled journey towards there.
  • The former will lead to a surge of infections so high that the healthcare system cannot cope, and people will die for lack of oxygen supplementation because there is no room for them. But the country will also reach endemicity faster.
  • So what is slowing down countries like Singapore who are proponents of endemicity from being the first to reach this endemic state?
  • The answer is simply the human cost because all lives matter. And that is why Singapore is among countries in the world with a low Covid-19 death rate.
  • As long as a country has not reached endemicity but is in the process of moving towards endemicity, whenever the caseloads in hospitals become more manageable, restrictions may be eased.
  • This of course means cases will go up again, and then restrictions will have to be re-imposed again. Thus, depending on the surge of each wave, restrictions may be eased or re-imposed.
  • This is not a flip-flop. Neither does this mean the government and policymakers in Malaysia are clueless when you see this surge of cases. They are persevering towards endemicity to ensure the healthcare system remains intact to take care of you.
  • Hence, moving towards endemicity is not going to be a pretty sight.
  • It is good that when the Omicron first made its appearance in Malaysia, Khairy and the Director General of Health, Tan Sri Dr Noor Hisham Abdullah immediately started the efforts to prepare for the possibility of a surge in Covid-19 cases due to the Omicron variant.
  • “There may be an increase in patients that require a short stay in the hospital particularly among high-risk groups such as senior citizens, individuals with comorbidity and children, which will pressure the healthcare system in the country,” said Dr Noor Hisham.
  • As such, he added, the ministry has turned district hospitals into hybrid hospitals to treat Category 1, 2 and 3 patients.
  • While patients under Category 4 and 5 will be referred to specialist hospitals, stable cases will be isolated at home, monitored by Covid-19 Assessment Centres (CAC) till the isolation period ends.
  • Moreover, patients will be treated with identified antiviral medicine at early stage at the CAC and the Covid-19 quarantine and treatment centres.
  • Dr Noor Hisham also stressed that the whole-of-government, whole-of- society approach is vital in ensuring there is no surge in Covid-19 cases caused by new variant.
  • “Hence, continue to adopt and strengthen self-control, continue to comply with the SOPs and get vaccinated so that Covid-19 cases can be under control in the country,” he added.
  • This early preparation has made it possible for the healthcare system not to be overwhelmed even when the daily cases reached five digits, say 25,000 which means about 125 hospitalised patients.
  • But this preparation was made before the Chinese New Year public holidays and even before the Johor state assembly was dissolved.
  • As mentioned earlier because the five-digit daily infection is not a one- day, one-off affair, sooner or later, this increase in daily infection will impinge on the healthcare system.
  • Already Khairy was reported to have said on Feb 17 the number of hospitalisations due to Covid-19 has grown by 42% in the past week.
  • But, he explained, this was the result of a “pre-emptive measure” to ensure that patients’ condition do not get worse, as the majority of the hospitalisations were for people classified as Category 1 and 2, who are not considered to be severely ill.
  • “They have been admitted as a pre-emptive measure so that they can be monitored and (we can) ensure that their condition does not deteriorate. We only admit those who are considered to be high-risk such as those who have comorbidities, or those aged 60 years and above.
  • “Because of this policy, the number of hospitalisations will increase in tandem with the increasing number of Covid-19 cases,” he said during a press conference on Feb 17.
Read more on zero-Covid strategy, endemicity and border opening:
  • Proponents of endemicity need to specify quantitatively the parameters that constitute endemicity so that it is very clear to all what endemicity means.
  • The first parameter is quite easy to specify i.e. capacity of the public healthcare system based on the bed utilisation rate in intensive care unit (ICU) wards.  
  • This is necessary because endemicity must be associated with infections that will not paralyse the healthcare system. 
  • Hence, a warning system should be developed to let all especially frontliners know whether at any point in time the healthcare system can cope with the number of daily infections. 
  • For example the use of colour coding where green denotes bed utilisation rate in ICUs of below 50%, orange denoting a utilisation rate of 50% to 80%, while yellow is a rate of between 80% to 100%, and finally red, above 100%. 
  • As long as this rate is in the green or orange colour, the situation is endemic because the hospital can cope with the rising infection. 
  • The first sign of danger is yellow when the rate is 80% to 100%, which means this is the time where private hospitals need to be roped in to increase the capacity of the healthcare system before it gets overwhelmed. 
  • Once the bed utilisation rate is 100%, then the army would have to be roped in to set up more field hospitals. 
  • But of course like what KJ and Noor Hisham did, once there is the information that a new variant has entered the country, the policymakers can take a proactive approach while still at the green level by expanding earlier the capacity of the healthcare system to prepare for the possibility of a surge in Covid-19 cases. 
  • With the capacity of the healthcare system being taken care off, this means endemicity is sustainable.
  • The next parameter is the death numbers. Proponents of endemicity say that we can really move very fast towards the true state of endemicity in as short a time as possible by removing all restrictions, and open all borders, but that this will lead to a surge of infections so high that the healthcare system cannot cope, and people will die for lack of oxygen supplementation because there is no room for them. 
  • Hence, it is the human cost because all lives matter that has prevented the proponents of endemicity from implementing this superfast approach. But what does all lives matter means when obviously we know that the infections will cause some deaths. 
  • So what are the death numbers that we can live with during endemicity?
  • One way to arrive at a proxy number is to compare it with other endemic virus like the common cold. 
  • From the average figures of deaths per day/week/month/year caused by the common cold in the past 10 years, we can then use this average figure to denote the number of deaths that’s consistent with endemicity.
  • Finally, specifying quantitatively the parameter on daily cases “when the virus is circulating among us without being the threat that it is now”. This is very difficult to determine.
  • Once upon a time, when the daily infection figures were consistently in the three digits, this was considered as threatening enough to merit a movement control order (MCO) such as the first ever MCO implemented in March 2020.
  • The last time we had a three-digit daily infection was in September 2020 after the Sabah state election. At anytime now, if we ever reach a three digit daily infection, I’m sure all of us will heave a sigh of great relief and no longer consider such a daily infection number as the threat it used to be.
  • So, what this means is the daily infection number consistent with endemicity is a moving number like a moving average, depending very much on the surge of each wave.
  • For now that number could be below 5,000 cases a day because before we experience the current 5-digit surge, the daily infection numbers were hovering below 5,000 cases for quite a long time, accompanied by the feeling that things are quite normal as if we are already in an endemic phase.
  • When tragedy struck, the sole solace is to see how it brings the best in us together to help the victims.
  • There is a Chinese saying that goes: “If you want happiness for an hour, take a nap. If you want happiness for a day, go fishing. If you want happiness for a year, inherit a fortune. If you want happiness for a lifetime, help somebody.”
  • For centuries, the greatest thinkers have suggested the same thing: Happiness is found in helping others.
  • The response of Malaysians in helping the flood victims is just incredible and praiseworthy – from donation drives, to providing shelter, and rescuing people including a cat from the rising water.
  • There’s even one NGO catering assistance specially for flood victims who have disabled children.
  • Blessed are those who help others in extraordinary time for they are the embodiment of humanity at its best!

Let’s Talk! PRESENTS: While a zero-Covid path is one approach that denotes the end of the pandemic, another approach which is getting traction is the endemicity path to mark the return of normalcy in life after more than two years of living dangerously with the pandemic. While the zero-Covid path is very easy to grasp, the endemicity path is not that easy to grasp especially in term of how or when we’ll reach endemicity, or whether we’ll reach it at all. JAMARI MOHTAR explores what endemicity entails.

Endemicity – Are We There?

By Jamari Mohtar

As mentioned in an article (Sustaining endemicity in pre-endemic time), it was misnomer to think that we are already in an endemic stage. Those who thought so is focusing on the definition of endemic as co-existence with the virus per se, when the correct definition is co-existence with the virus without a staggering loss of lives, so that normalcy will be the order of the day.
    When the article was written on Oct 31 last year, the death figure was 37. On Feb 22 this year, it was 43 deaths followed by 55 the next day. The last time the daily death number was zero was on Dec 4, 2020.
      After more than three months since the article was written, the daily death figures have increased though still in the two digits. We have come a long way to this situation after going through much trial and error in combatting the scourge.
        It is not only in Malaysia that there was trial and error, as Covid-19 is a new animal that has caught many governments operating in a context of radical uncertainty, being faced with difficult trade-offs given the health, economic and social challenges it raises.
          Already there are two approaches in combatting the pandemic. One is the zero-Covid path with its emphasis on lockdown, border closure and strict preventative measures which were being implemented successfully by countries like China and New Zealand, among others.
            The other approach is via the endemicity path whose proponents include Singapore, Malaysia and many European countries, which is based on the notion that the virus is here to stay for the long haul.
              Hence, to achieve a zero transmission is almost impossible and we just have to learn and live with it. But the endemicity approach is yet to see any success so far because it is still a process or a transition towards endemicity i.e. work in progress.
                According to a Harvard infectious-disease expert, Yonathan Grad, ‘this distinction between pandemic and endemic has been put forward as the checkered flag,” a clear line where restrictions disappear overnight, Covid-related anxieties are put to rest, and we are “done” with this crisis.
                  That’s not the case. And there are zero guarantees on how or when we’ll reach endemicity, or whether we’ll reach it at all.
                    Many are clueless on what endemicity is all about and hence, fail to distinguish between the process and the end result.
                      The endemicity approach is hinged on one basic premise – a truly endemic state is reached when the virus is circulating among us without being the threat that it is now and without a large number of hospitalizations.
                        The problem is proponents of endemicity have never specified the digit of daily transmission that constitutes a non-threatening situation. Given that an endemic situation is one where it is impossible to attain a zero transmission, so does a one-digit, two-digit, three-digit or four-digit daily infection constitutes a non-threatening situation?
                          This failure to specify has led to many saying that the daily infection number is not important, as what is important is that serious cases are below 1% of the total daily cases.
                            But what if the daily infection number is in the six digits, as happened in many Europeans countries as early as last month? Assuming the daily case is 100,000 and 0.5% of this are serious cases that would mean 500 serious cases needing ICU beds, oxygen supplementation and ventilators.
                              Seeing that a hospital would normally have 1,000 beds, out of which about 300 to 500 are ICU beds, 500 serious cases are manageable only if the six digit daily case is a one-off event.
                                But as experienced in many countries, once the five or six-digit figure is hit, it will go on and on for at least a week or so, sometimes longer, and those who were hospitalised will not be discharged for the next three to four days because these are serious cases we are talking about.
                                  This will put a tremendous pressure on the healthcare system, resulting in poor care of the patients, which will have a knock-on effect in term of simultaneously raising the death rate and the transmission rate, even among the frontliners.
                                    An important cornerstone of the endemicity approach is you cannot reach endemicity without the waves of transmission because there can be no natural immunity without infections.
                                      High natural immunity (used to be called herd immunity) in the community can come about only when people are infected, so say the proponents of endemicity.
                                        The more infections there are (and people recover from their infection), the greater will be the natural immunity in the population. This is why you cannot reach endemicity without the waves of transmission.
                                          With every wave of transmission, the natural immunity in the population also increases, making the population more resilient.
                                            The main weakness in this argument lies in assuming people who are infected will necessarily recover. Some don’t and become a statistic in the daily death number, while others may regress from Category 1 to 2 or from 2 to 3 and so on.
                                              The fact that in most countries during waves of transmission, the daily recovery number is always less than the daily infection number shows that this argument should be treated with a pinch of salt.
                                                Moreover, it will only lead to an act of stupidity in wanting to get infected so that your natural immunity will increase.
                                                  There is, however, a merit in the argument that endemicity doesn’t mean an attempt to stop the transmission, as it aims only at slowing it down to ensure the healthcare system is not overwhelmed so that every sick person can be cared for.
                                                    And this is also the reason why some restrictions are still in place, which means it is a process towards endemicity because when endemicity is reached, there shouldn’t be any restrictions.
                                                      So people should get it in their head that endemicity is a long process, and there is still a need presently to observe restrictions and its SOPs and be circumspect when you have to go out in the open.
                                                        This does not mean you cannot go out of your house. It is just a personal decision with responsibility i.e. you decide whether it is necessary to go out. If it is, by all means go! Just take the necessary precautions. Otherwise stay at home.
                                                          While the daily cases is on the rise and constitute a threat to the situation, opening of the borders must be done gradually and with some restrictions.
                                                            It is indeed not the time to do away with mandatory quarantine in opening up the borders. Even when endemicity is reached, mandatory quarantine is always a must for positive cases.
                                                              So it very disturbing and worrying for people to react with joy whenever the proposal of removing mandatory quarantine is mooted.
                                                                What can be done is gradually to remove quarantine by first reducing its duration. Quarantine used to be two weeks at the start of the pandemic.
                                                                  Now it is five days for asymptomatic close contacts with booster jab, seven days for asymptomatic close contacts that are fully vaccinated and 10 days for the asymptomatic, unvaccinated close contacts.
                                                                    This can be reduced further to three days, five days and seven days respectively once the threat of a rising daily cases has subsided.
                                                                      During the early days of the pandemic, if you’re positive, you had to be quarantined for 14 days. Now, it’s seven days if you’re fully vaccinated and asymptomatic, and 10 days if you’re not fully vaccinated or unvaccinated and you’re symptomatic.
                                                                        Moreover, even if you’re positive but as long as you’re asymptomatic (Category 1) or having mild symptoms (Category 2A) and are not in the high-risk category (i.e. below 60 years old and have no comorbidity), you’re allowed to be quarantined at home.
                                                                          A day will come when these quarantine period should be reduced further to lesser days than it is now, and a truly endemic stage will see all mandatory quarantine will be a home-based one that are limited to the positive cases only.
                                                                            Malaysia is moving towards this direction when on Feb 25, Health Minister Khairy Jamaluddin announced individuals above the age of 18, who have taken their booster jab will no longer be required to undergo a Home Surveillance Order if they don’t show any symptoms of the disease after coming into close contact with a Covid-19 positive case. This will take effect on March 1.
                                                                              Also due to the fact that imported cases are relatively lower than cases via community transmission, we can start now by allowing all foreigners visiting the country including locals returning from abroad not to be subjected to mandatory or home quarantine if they are tested negative on arrival.
                                                                                All these moves to reduce the quarantine period, and making it easier for home quarantine are to be seen as the process towards endemicity.
                                                                                  When endemicity is reached, even close contacts should not be quarantined as long as they are negative and don’t show any symptoms.
                                                                                    As long as a country has not reached endemicity but is in the process of moving towards endemicity, whenever the caseloads in hospitals become more manageable, restrictions may be eased.
                                                                                      This of course means cases will go up again, and then restrictions will have to be re-imposed again. Thus, depending on the surge of each wave, restrictions may be eased or re-imposed.
                                                                                        This is not a flip-flop. Neither does this mean the government and policymakers in Malaysia are clueless when you see this surge of cases. They are persevering towards endemicity to ensure the healthcare system remains intact to take care of you.
                                                                                          Hence, moving towards endemicity is not going to be a pretty sight. Already Khairy was reported to have said on Feb 17 the number of hospitalisations due to Covid-19 has grown by 42% in the past week.
                                                                                            But, he explained, this was the result of a “pre-emptive measure” to ensure that patients’ condition do not get worse, as the majority of the hospitalisations were for people classified as Category 1 and 2, who are not considered to be severely ill.
                                                                                              “Because of this policy, the number of hospitalisations will increase in tandem with the increasing number of Covid-19 cases,” he said during a press conference on Feb 17.
                                                                                                  Regards, Jamari Mohtar
                                                                                                    Editor, Let’s Talk!

                                                                                                    Let’s Talk! is a free, monthly e-mail service on current happenings in Malaysia brought to you by Usrafalah Sdn Bhd. It is edited and managed by a group of volunteers.

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