Health and public policy experts moot more specific thresholds for Malaysia to exit Covid-19 crisis

Health workers conduct a Covid-19 swab test in Bandar Tun Razak, Kuala Lumpur June 5, 2021. ― Picture by Shafwan Zaidon
Health workers conduct a Covid-19 swab test in Bandar Tun Razak, Kuala Lumpur June 5, 2021. ― Picture by Shafwan Zaidon

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KUALA LUMPUR, June 19 — The National Recovery Plan (NRP) thresholds need to be more specific if Malaysia is to escape from the yo-yo cycle of the Covid-19 pandemic and recover socio-economically, health and public policy experts said.

Epidemiologist Dr Helmi Zakariah said the first threshold listed in the government’s NRP, for the daily infections nationwide to fall below the 4,000-mark, is an arbitrary figure as there is no epidemiological evidence of whether a certain value could potentially be a pivotal point where outbreak will spread out exponentially.

He added that preferring round figures or arbitrary numbers as a nationwide indicator rather than the positivity rate will not show the variability of the positive cases from different places.

“In short, the 4,000 figure across the country is hardly meaningful because there can be a scenario where it’s all zero in different areas, but 4,000 in Klang Valley. This is of course an extreme example but this is what I meant where ‘round figures’ cannot be meaningful for a nationwide indicator,” he told Malay Mail when contacted.

The positivity rate, also known as per cent positive, shows the percentage of positive Covid-19 cases detected out of the total tests conducted and helps public health officials find out the current level of virus being transmitted within the community.

A higher positive rate means that more testing should be done and suggests restrictions to slow the spread of the disease should be maintained, or even increased. — Picture by Hari Anggara
A higher positive rate means that more testing should be done and suggests restrictions to slow the spread of the disease should be maintained, or even increased. — Picture by Hari Anggara

The World Health Organisation has set a positivity rate of 5 per cent as the threshold but Malaysia averaged 6.89 per cent in the last week of May, as announced by Health Minister Datuk Seri Dr Adham Baba on May 31.

A higher positive rate means that more testing should be done and suggests restrictions to slow the spread of the disease should be maintained, or even increased.

Dr Helmi, who is a member of the World Health Organisation-International Telecommunication Union Working Group for Artificial Intelligence in health, suggests that a good indicator should not mention only the daily positive case but also disclose the number of tests that have been performed.

“Imagine the positivity rate in many other areas in Malaysia is 1 per cent, and specifically in Maluri, Cheras is 27 per cent. What would happen to the average national positivity rate?

“Yes. The moving average will go down and this doesn’t reflect on the fact that in Maluri, Cheras [there are still] hotspots that are active,” he added.

Health officers conduct the Covid-19 antigen rapid test. — Picture by Choo Choy May
Health officers conduct the Covid-19 antigen rapid test. — Picture by Choo Choy May

Khazanah Research Institute researcher Nazihah Muhd Noor shared a similar view. She said that without stating the positivity rate, the daily positive infection rate could be misleading if there was less screening conducted.

She added that the positivity rate should come together with the daily infection rate so that the people are well informed on whether the infection it’s really declining or it is just the “reported” number of cases.

“The number of daily cases only tells us a part of the story. Simply put, if we are testing fewer people, we will see fewer cases. The test positivity rate should be used together with the number of daily cases to help us assess whether the actual number of cases are really declining, or whether it is only the reported number of cases that is declining.

“On this, we must continue to implement widespread and frequent testing. Until Covid-19 is truly gone, we cannot be complacent with testing even if the number of cases appear to be falling,” she said.

While she praised the use of epidemiological indicators in the NRP as a guideline to relax restrictions, Nazihah said that listed those indicators as “targets” is insufficient. Just as important was how the targets would be achieved.

“For example, what is our strategy to ramp up vaccination rates and registration, while at the same time ensure that typically underserved groups are not going to be left behind? How are we going to support the healthcare workforce who are the backbone of the healthcare system? How are we going to hold employers at workplaces such as factories and construction sites accountable for protecting the health of their workers, including foreign workers, especially undocumented ones? 

“From a welfare perspective, what are the additional assistance programmes that will be made available to households and small businesses who are struggling financially while the restrictions are in place? 

“We cannot argue that the restrictions are necessary for public health reasons and without also providing direct financial assistance to people to mitigate the effects of the restrictions,” she said.

Workers in PPE suits carry the body of a person who died from the coronavirus disease (Covid-19) at a Christian cemetery in Semenyih, Selangor. — Picture by Shafwan Zaidon
Workers in PPE suits carry the body of a person who died from the coronavirus disease (Covid-19) at a Christian cemetery in Semenyih, Selangor. — Picture by Shafwan Zaidon

Tricia Yeoh who heads local think tank Institute for Democracy and Economic Affairs (IDEAS) said the government needs to provide concrete and quantitative measurements to better explain the meaning of the terms “moderate” or “sufficient” during the announcement of the NRP last Tuesday when describing the hospital bed occupancy.

“Measuring the capacity of public health facilities is good, but the government did not disclose the definition of what ‘moderate’ and ‘sufficient’ means. There needs to be more transparency in indicators moving from phase to phase,” she said.

Yeoh said IDEAS would also like to propose a national pandemic severity index that will provide clearer indicators of the growth or reduction of the disease, based on positivity, infectivity, and fatality rates.

To Dr Helmi, Malaysia right now has a steep hill to climb to achieve herd immunity against Covid-19. He said this is because of factors like procurement and stability of the vaccine supplies, eligibility, affordability and complexities of logistics.

“This is in contrast with a more mature vaccination programme like the 95 per cent coverage threshold for National Childhood Immunisation programme for measles, for example.

“I think we are in for a steep, if not long journey, in terms of the vaccination rate. 

“So I guess now the question to the policymakers is: are we willing to give up the control of our economy, social needs and care, and democracy to the instability of global vaccine supply?” he asked.

Prime Minister Tan Sri Muhyiddin Yassin announced the four-phase NRP last Tuesday. — Bernama pic
Prime Minister Tan Sri Muhyiddin Yassin announced the four-phase NRP last Tuesday. — Bernama pic

The four-phase NRP announced last Tuesday by Prime Minister Tan Sri Muhyiddin Yassin came with three threshold indicators to decide if and when Covid-19 pandemic restrictions will be lifted and in what stages.

He said each phase will be based on thresholds that will look at the daily Covid-19 case average numbers, the capacity of the public health system, and the vaccination rate of the general population.

Muhyiddin said each phase will see more restrictions towards economic activities and the social sector ease up as each of these thresholds reach a more satisfactory level, with the fourth and final phase expected to be imposed only towards the end of the year.

Under this plan, Malaysia is currently under Phase One, which will move to Phase Two by July if new cases dip to under 4,000, vaccination rate reaches 10 per cent, and intensive care unit’s usage falls to “moderate” level.

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