The Covid-19 outbreak is now a full-blown pandemic. In Malaysia, we are beginning to see extensive spread with cases in all states. No longer is travel history or contact with a known case of value, as Covid-19 is spreading in the community. We have to assume it is in our neighbourhood.
There is increasing data and studies that suggest asymptomatic or pre-symptomatic infected individuals (infected individuals who look well) can also transmit the virus. In the current situation, the way to live is to assume many around are infected and practise social distancing and good hand hygiene.
We must not squander the gift and time that China gave us through the Wuhan lockdown. We must not lose the value of the experience we are gaining from Italy. We are not as strong or as swift as them. Our healthcare system cannot cope with a coronavirus explosion and we may lose many lives.
We need to act together and not resort to panicking. We need to be concerned and use that worry to “get our act together”. We cannot just expect the health ministry (MOH) or the government to do it all; they cannot. Social responsibility on our part is what will make the difference between mindless panic and a nation that rises to meet this challenge together.
We have three goals in this pandemic right now
1. Flatten the curve (or stop the spread completely).
We must work together as a nation to mute the epidemic, retard its spread. This will, of course, make it last longer but will buy us the valuable time we need. It will allow us the opportunity to work at completely stopping the spread.
2. Give the health services time to cope.
The time we obtain by flattening the curve will give our already stretched health services the ability to manage cases better, get more prepared and last this “marathon”. We need this time to save lives.
3. Save our older and fragile fellow Malaysians.
By retarding the epidemic we can reduce the number of older family members and friends, as well as those with chronic illness, from getting infected and seriously ill. Smaller numbers getting ill will allow for better care and we do not have to do the unthinkable that is happening in Italy. Despite the excellent healthcare system Italy has, they had to deny care to infected older persons with poorer outcomes as their system is overrun. Also remember that an overstretched health service cannot cope well with the usual severe illness of all ages that are admitted to hospitals.
The “best case scenario” for us is that the outbreak may escalate in the next two to four weeks, then peak two months after, followed by it subsiding, provided we get our act together. Then there will be the lingering (prolonged) long-term re-infection from overseas and local pockets which we can mop up. If we do not get our act together, we will face a sudden explosive outbreak with bad outcomes.
There are 3 keys measures we can take to fight this epidemic.
1. Social distancing.
This is the key to breaking the transmission (spread) of the coronavirus outbreak. Make it our “mantra” – social distancing, social distancing, social distancing. We need to shut down many activities. Meeting in small groups is just as hazardous as large groups. So, saying groups below 50 or 100 or 200 are allowed to meet will not stop this outbreak. Stop all meetings, workshops, conferences, religious gatherings, schools, universities, weddings, dinners, celebrations, night clubs, etc. Intimate small group meetings like prayer meetings or small social gatherings and late-night mamak outings are also at risk of spreading the virus.
Stop travelling and stay at home. Limit your excursions outside the home. This does mean that we will need to be creative on how to use our time at home as well as keep fit. Those in education must put in place online education and telelearning. Employers need to institute work from home and teleworking.
Even MOH press briefings on coronavirus must institute a 1m distancing for reporters and staff. Social distancing measures will be difficult for everyone but can be achieved if we all work together as a community and support each other.
2. Hand washing/hand disinfection and avoiding touching your face or surfaces.
Keeping our hands clean when we are out of the home is critical. Always carry an alcohol-based hand sanitiser. Avoid kissing, shaking hands, hugging or touching others unless that is absolutely necessary. Don’t touch any surface unless absolutely necessary. Avoid crowds and crowded areas. If someone in public is coughing or sneezing, keep your distance from them and ask them to put on a mask (3-ply surgical mask or N-95 mask). Consider carrying some spare masks and offer them to individuals who cough or sneeze.
3. Good information and avoiding disinformation.
There are many false ideas and suggestions circulating and it is important we verify them before sharing with anyone. It is best to check with accredited sources or read reliable sites. Do not spread fake news on treatments, deaths or outbreak sites. The epidemic is fluid and everyone needs to keep up-to-date with the latest information so that we can work as a country and a global community to deal with this threat.
Some suggestions for specific circumstances and situations
For those who become unwell with coronavirus (flu-like) symptoms.
If you have some fever, running nose or cough you need to assume that you may have the coronavirus. Note that testing will not be possible for the vast majority of persons as tests are limited and we should reserve them for contact tracing, stopping clusters, seriously unwell individuals and older ill persons.
It should be the responsible thing to tell your employer or your school or university that you are unwell and refrain from going back until you are well. What you should do is to self-isolate (except for young children who will need one parent to be with them). If possible, use a bedroom with an attached bathroom and stay away from everyone, including your family. Your family or friends should be responsible to bring you food, left outside the door, and utensils returned should be picked up with gloves to be washed thoroughly with soap and water. Avoid sharing towels and any items for personal hygiene (e.g. toothbrushes).
There is some evidence for Covid-19 to spread by stool (faeces). Flushing of the toilet should be done with the lid down and toilet bowl covers should be cleaned periodically.
You will need to keep yourself meaningfully occupied by reading, using the internet, etc. This could be a good time to connect deeper with our Creator. If you are well enough, you can do light exercises in the room or garden. How long should you remain in self-isolation? This is uncertain. At least seven days but possibly 14 days.
Supporting older family member and those with chronic illness who are currently well.
Our major concern is saving the lives of our older loved ones and those with chronic heart, lung and other conditions (hypertension, diabetes, chronic lung damage, etc). We should consider if they should be semi-isolated from the community. The minimum you should do is to make sure they have two to three months of their essential medication available. Also have some excess supplies of food for them in case the outbreak gets worse. Limit visitors and limit their excursions into the community. Do not share food (i.e. no saliva transmission) within the family. It is best to have a spoon for every dish and use that to put items onto your plate and not take food directly from the dish with your spoon or chopsticks or hands. If older persons become ill you should contact MOH to check about testing for the coronavirus.
Dealing with eating out.
If possible cook at home or buy back. If you buy back food, use your own utensils to “tapau” the food, and avoid the shop’s plastic or styrofoam containers. If eating out, think about all the surfaces and people you are going to be in contact with and how to limit this. My wife and I have an “anti-coronavirus kit” that we carry with us when we go out. We have our own personal chopsticks, forks/spoons and cups to use. We find most food outlets appreciative and supportive of our behaviour. We also carry masks for emergency use (or to share with others) as well as alcohol sprays and hand sanitisers.
There is good data that this virus can survive up to 48-72 hours on many surfaces. So the first thing we do is try and open the door with our foot. If that is not possible, we swab or spray the door handle with alcohol before touching it and once inside, we disinfect our hands with an alcohol-based hand sanitiser.
We then choose a corner table or open-air section, distancing ourselves from others, and clean the surface of the table with an alcohol spray using a paper kitchen towel.
Remember to be respectful of others and don’t leave your dirty tissues behind, especially those used to clean your mouth and nose, as it may infect others if you are infected but are unaware. Avoid using a straw for drinks unless absolutely necessary, perhaps for a person with a disability. Straws are picked up by the fingers of the person serving you and then put into your drink and then you put your mouth on the straw – a high-risk event.
We tend to eat at places we already know and trust the hygiene of the food handler. We educate all food-handlers and servers to routinely use a transparent kitchen mouth shield (mouth or spit guard). They are not expensive and can be reused after cleaning. We also teach them to clean the tabletops in between every customer using an alcohol-based spray. Also note that it is best to pay using electronic means to avoid getting back change. If you have to pay in cash, give the extract amount or forego some change.
Suggestions when shopping at the supermarket.
We will have to make intermittent visits to the supermarket to stock up on food, supplies and other essentials. Be mindful of the trolley bar that we hold. Best to clean and wipe it with an alcohol spray. Best also to bring your own bag to avoid using supermarket plastic bags except for wet items/meat. Try to keep a distance from other people as much as possible, especially at the check-out counter. Be careful with touching lift buttons, travelling in lifts, and car park buttons.
Dealing with school holidays and school closures.
School holidays are here and have the potential to spread the virus widely. It is best that we do not travel. Please don’t say “because I have paid in advance, ‘sayang’ (it would be a shame) to lose the money”. Better not to infect others or get infected. If you travel, avoid travelling in an enclosed environment with others, like in a plane, taxi, bus or train.
We expect that our nation may have to take the extraordinary step of shutting down all schools, colleges and universities for a period of time to stop the virus spreading. The best would be to allow parents to work from home and children/teenagers to have online classes. In addition, parents should consider activities that allow for social distancing but can still be rewarding, for example a walk in the neighbourhood, park or jungle, rather than allow all of us to be glued to electronic devices. If school closure happens, it may be a wonderful opportunity for families to reconnect with each other, especially for parents to listen to their children.
Dealing with visits to the hospital or clinic.
Hospitals and clinics are higher risk locations to visit and we should avoid going to the hospital or clinic unless necessary. Those with planned visits for chronic illness should try and arrange for limited waiting times. This would mean that we can arrive 10-15 minutes before the visit, see the doctor and go off quickly. This can be arranged if we improve the efficiency of our health services at this time and offer mobile appointment services.
We must limit the number of people waiting to see a doctor in the clinic or hospital specialist waiting areas. If you are unwell, tell the counter staff immediately when you arrive, so that they can give you a mask and keep you away from others.
Now is the time to work together and share our resources. If you have extra masks and hand sanitiser, consider sharing with those who do not have any. If you have some financial resources, consider sharing it with the poor or those who will be hard hit by the loss of daily paid jobs.
This outbreak will show us who we are as Malaysians and teach us many things about ourselves.
I hope we have the courage, humanity and respect for others that will see us through this trying time. The risk for some of us is small but we must consider the best interest of everyone. Our joint social responsibility is what will make a difference in this epidemic.
Dr Amar-Singh HSS is a senior consultant paediatrician.