By Dr Rais Hussin, Dr Margarita Peredaryenko and Ameen Kamal
A nationwide full movement control has been in place since 1 June 2021. Although it has brought some respite and easing of the pandemic situation in some of the states, the condition has been seriously worsening recently in the Federal Territory of Kuala Lumpur (KL) and Selangor, with record numbers reportedly contributing more than 60% of the new cases in the country.
KL and Selangor’s consistent R-naught value of above 1.0 may be reflective of increasing transmission, and the increasing cases are pushing healthcare capacities in the region to breaking point. The spread between new cases and recovered cases that started to widen early last week (July 4) was the red alarm indicating healthcare systems struggling to cope with surging cases. This prompted the authority to enhance MCO in most areas in KL and Selangor from July 3 to July 16.
The overall testing intensity nationwide has been on a general decline while the test positivity rate has been soaring higher (Figure 1).
Figure 1: New cases, new tests and positivity rate by weeks (Data Source: Ministry of Health, Malaysia)
Although, according to the state breakdown figures published earlier, some states are testing more than others, including KL and Selangor.
Despite KL and Selangor testing more than most states (especially Selangor with testing numbers roughly two to three times that of KL), the corresponding high test positive rates could indicate that the spread may already be too wide. Therefore, Selangor should focus on containment strategies and vaccination while ideally maintaining the relatively higher levels of testing. Other states, including KL, may need to increase testing alongside strict containment and vaccination.
In consideration of resource allocations, we refer to our suggestion that the testing exercise ride on the vaccination campaigns, utilising the same place and manpower available.
However, the situation is complicated by the fact that KL and Selangor are the busiest business areas. Every day of the prolonged and stringent lockdown brings more Micro, Small and Medium Enterprises (MSMEs) closer to the cliff. Therefore, the situation requires urgent, strategic, multi-prong and unprecedented response to not only alleviate the situation but to minimise the possibility of its painful recurrence.
To achieve this, EMIR Research builds on our earlier “Exit Strategy Building Blocks for Malaysia” published on Jun 17, 2021. The three main goals remain:
1) complete lockdown,
2) extending safety net to KL and Selangor, and
3) speed up vaccination.
However, given the urgency of the situation, whereby every day matters, we bring in new and important strategic tactics based on robust scientific evidence.
Firstly, the total lockdown is crucial. If done correctly i.e., a real “total” lockdown in KL and Selangor for at least two weeks to a maximum of six weeks as was intended at the start of the movement control, it will help cut transmission, slow down new infections and ease the distressful healthcare situation in these states.
Secondly, extended strictness and time of the lockdown will require deepening the social safety net for the vulnerable lives and businesses in KL and Selangor.
Among the specific recommendations which EMIR Research would like to reemphasise again is the automatic opt-out loan moratorium and enhanced renters’ protection for all — individuals and MSMEs in KL and Selangor. The basic principle of financial management tells us that it is possible to survive the income downfall if you can reduce your operating and financial leverage — this is where the government will need to deepen its approach.
Therefore, to mitigate the proposed total lockdown in KL and Selangor, the government should mandate and closely monitor the implementation of a true automatic opt-out loan moratorium for all with no change of terms or interest / fee charge attributed to the months of the moratorium period. This is a serious issue as some banks may still try to leverage the “opt-in” feature.
At least for KL and Selangor, the government should also consider changing the incentive approach with the landlords into the form of temporary law measures similar to other countries. For instance, the government could temporarily mandate equitable co-sharing of rental obligations between the government, landlords and tenants and make eviction illegal, at least until we transit into Phase Three of the National Recovery Plan. The biggest share should be by the government, followed by the landlords, and minimally (or none) borne by the tenants.
Lastly, but not least, is to increase the rate of vaccination as thus far it has been our best bet against the raging pandemic and the only hope for speedy return to some form of normalcy.
The objective of massive vaccination is to at least protect a larger proportion of population from the disease severity, hospitalisations, and deaths, even if infection was to happen. However, given, and only given the urgency of the situation, the same objective can be achieved through exploiting natural immunity to COVID-19 to win precious time and save lives and livelihoods. Notably, this idea has been mooted by the scientists since the start of 2021.
Eight credible peer-reviewed studies
To date, there are at least eight credible peer-reviewed studies published in reputable medical journals that aim to ascertain whether natural COVID-19 infection offers protection against this infection and how lasting it is.
All eight studies are done in various periods during the year 2020 (before the vaccines), in various countries such as Austria , Denmark , Qatar , Switzerland , United Kingdom [5, 6], United States [7, 8]. Two were done among the healthcare workers while the rest on a nationwide samples.
To trace infection or reinfection these studies used PCR tests, serological tests or both. Importantly, those who used both approaches found remarkable similarity in their results.
Unanimously, these studies established the strong empirical evidence of protection from COVID-19 following natural infection (estimated efficacy ranging from 79% to 95%) lasting seven months on average among these studies (as seen from the range of the observed period where this estimated efficacy was measured). Interestingly, both studies at the lower side of the efficacy range have been done in the medical setting where lower efficacy could be explained by higher levels of exposure to viruses and higher viral load received.
Furthermore, three out of eight studies observed the protection rate increasing towards the end of the observation period. Importantly, the majority of reinfections were asymptomatic or with mild symptoms. Only five cases of hospitalisation after re-infection were reported across the studies and only one study reported one death out of 14,840 previously infected people, involving a 72-year-old person.
These findings are especially important in the view that available antibody assays measuring neutralizing antibodies may observe lowering antibody titre after a few months post infection, which is also a scenario that has been reported for Covid-19.
However, the protection against severe symptoms, strong evidence of which we observe in the above studies, could be manifestation of the fact that the protection of the immune system involves more than just antibodies and includes other important immune actors such as T cells and B cells, which may not be measured in current COVID-19 assays and may play an important role in what we observe. This is a well-established mechanism of immune response to many diseases.
Due to the significant cost involved in capturing this deeper immune response, the relevant studies are rather scarce. One such very recent longitudinal study published in Science, a peer-reviewed academic journal, assessed the immunological memory to SARS-CoV-2.
By continuously examining the blood of 254 COVID-19 confirmed cases (aged 19 to 81), the scientists established that despite antibodies against SARS-CoV-2 spike and receptor binding domain (RBD) declined moderately over eight months, memory B cells against SARS-CoV-2 spike actually increased between one month and eight months after infection. About 95% of subjects retained immune memory at about six months after infection.
Therefore, all these findings very plausibly suggest the possibility to exploit natural immunity and prioritise vaccination for those never been infected at least in the short-term (which can be as long as seven months post infection) in the situation of shortage of either vaccine or time or both.
The only exception should be naturally infected elderlies (as one study did find significantly lower protection of those 65 and above), people with comorbidities and those whose vascular and other vital systems have been severely damaged during the first infection.
This approach also capitalises on the vast number of people infected in KL and Selangor, which may be excluded first, to make way for others to be vaccinated. In other words, there are justifiable grounds based on empirical studies that most of the infected people would retain infection immunity within the said months, or at least, would still have protective immunity against severe symptoms. Therefore, in practice, particularly in an extraordinary emergency setting, these individuals may be treated like “vaccinated” individuals for a set period of time.
Door-to-door vaccination for the bedridden
Thus, by temporarily excluding these individuals, the target of maximising protection to the population of KL and Selangor may be significantly expedited. As vaccine doses arrive in the span of the coming months, these naturally infected people that were postponed for their vaccination, can then start to receive their jabs.
The efforts to increase throughput of vaccination in KL and Selangor such as door-to-door vaccination for the bedridden can also supplement the vaccine prioritisation/postponement strategy.
It must be stated here that this does not mean getting infected is a good strategy, especially when we have vaccines. It is only an emergency measure in view of the need to speed up population protection and/or in the backdrop of vaccine scarcity. Fatality rates of infections without prior immunity (be it from vaccines or natural infection) appear to strongly suggest COVID-19 to be more lethal than your average flu. Some sources estimate the fatality rate is 10 times more than the common cold. Therefore, doing nothing and taking infection lightly will not be the solution and would be detrimental in the grander scheme towards recovery.
Following the above tactic, while in full lockdown the authorities should start with the factories, various service companies and construction sectors in KL and Selangor as they continue to be the largest cluster contributors. Therefore, and favourably enough to this strategy, the large number of workers might be already protected with the natural immunity.
The authorities may start with first screening workers’ IC / ID in the national epidemiological reporting system among previously PCR-confirmed cases and exclude those who are falling within the aforementioned protection period. For example, if the postponement period target is one month for the naturally-infected population, then we can consider only those that were infected and recovered in the last six months.
Beyond one month of this strategy, the infected people can then be treated normally given the assumption that we have no vaccine supply issue and that by this time most, if not all, of the population in KL and Selangor have been protected.
New and emerging virus variants
For conservatism and in leaning even more towards safety, authorities may even consider a shorter period than the seven-month average duration, though the trade-off would reduce the number of eligible naturally-infected people that can be considered for exclusion.
One particular aspect that has not been directly addressed by the sources mentioned or studied is the impact of new and emerging virus variants against the immunity of naturally infected and recovered people.
It is postulated that these individuals may confer some level of protection against some variants (at least those that have not mutated too significantly) since natural infection may illicit not only the production of neutralising antibodies based on only one target antigen (like the spike, for example), but also triggering immune response involving other crucial immune components such as T and B cells by involving not only the spike but other parts of the virus that may be less susceptible to mutations. One way to begin elucidating and verifying this hypothesis is to also conduct antibody measurements and virus sequencing as mentioned earlier. Similar to the vaccine postponement strategy, any negative findings here may call for the approach to be reconsidered.
Overall, this strategy has a very calculated risk given the ample empirical support. Furthermore it can be treated as a case study and, if successful, extended to the other states of Malaysia. The rakyat (people) are suffering and require urgent, strategic, multi-prong and unprecedented response guided by science and economic needs.
Dr Rais Hussin, Dr Margarita Peredaryenko and Ameen Kamal are part of the research team of EMIR Research, an independent think tank focused on strategic policy recommendations based on rigorous research.