Is there another reason for the mandatory masks?

I am puzzled by the announcement that the use of face masks in crowded public place areas would be mandatory from 1st Aug 2020.

Don’t get me wrong.  If you have been following my blog, you will realize that I have been advocating for masks to be mandatory.

According to our Defense Minister, the use of face mask will be mandatory in crowded public areas and public transport with the usual fine or prosecution for non-compliance.

He said that the govt made the ruling following the increase in Covid-19 cases for the past 3 days and the lack of SOP compliance.

• 50% of those on home quarantine do not comply

• SOPs in public transport such as LRT, KTM were not complied with eg no social distancing and no face masks

He added that the govt avoided making it compulsory before because it was worried that the low-income group will face financial burden in buying the masks.  He suggested that according to WHO, people can make their own face mask.

Firstly, I am waiting to see how the govt will define crowded public areas.  Unless they make it compulsory for all places, I can imagine our enforcement officials having a field day.

But my main concern is the logic for the decision.

• Firstly quoting non-compliance among those returning (for not following self-quarantine SOP) does not make sense.  After all, it will be mandatory quarantine at designated centres so I don’t see wearing face masks as being relevant

• The second thing is that he quotes the rise in the number of cases

The chart below shows the number of cases for the past 15 days excluding the imported cases

We can see certain spikes.  And there are more cases among the locals c/w foreigners. 

If there was any concern about the increasing number of cases, it should be about the locals. 

Where is the source for the increase in the number of cases for the past 15 days?

I actually went through each of the MOH press releases for these 15 days to try to see whether these cases are due to people getting infected when in crowded public places. (Refer to the Appendix) 

Foreigners

The majority of the cases among the foreigners (in the local transmissions) are from one of the following: 

• Those in detention centres

• Those tested positive as part of the pre-departure screening

• Those from known clusters

Maybe there could be one or two whose source of the infection cannot be identified.

Locals

When it comes to the locals (Malaysians), again I found the following 

• the majority belong to some clusters ie they were tested positive following the contact tracing of some index case. 

• Quite a number were detected as part of the “standard” screening eg before surgery, workplace screening

Again I could not find any spike that is clearly attributable to people being in crowded places.  

The logic for making masks mandatory is that there is a spike in sporadic cases among the general public - MOH news announcement does not seem to suggest this. 

Like all things in Malaysia, I think the mystery (ie the real reason for the mask) will be known with time.

BTW if you look at the chart of daily cases, it would be legitimate to ask whether we are seeing an increase. 

A lot of the cases/clusters seem to be in Sarawak.  

There are currently about 161 active cases in the country (ie those still under treatment). Of these

• 60 odd are imported

• 58 are in Sarawak - with 47 in Kuching

• 19 in Johore

• 20 in Selangor/KL (the KL figures are only for those for the past 14 days)

So if there is any person who should be worried, it would be those in Kuching district.  The rest of the country still seems OK.

I would not worry about the imported in the coming future as they will be quarantined in special centres. 

But if I was in Johore I would also be worried.  Not so much the actual number of cases in Johore itself, but the increasing number of cases in Singapore.

The chart below seems to suggest the start of the second wave in Singapore.   It shows the daily number of cases, as well as the 7-days moving average (denoted as 7MA in the chart)

I don't want to be the alarmist but this was the pattern I saw in Australia a week before they declared a second wave and lockdown Melbourne.

So is there a real reason to be worried about Singapore?

If you breakdown the cases in Singapore into imported, community (ie those not in the dorms) and dorms (foreigners staying in dormitories) you can see that the majority of the cases over the past 4 weeks are still from the dorms.

The growth and/or the potential 2nd wave is still from the dorms.

It is still a mystery to me why Singapore has not been able to bring the number of cases in the dorms down given that the dorms sound like an EMCO area.  Maybe they should talk to our DG of MOH!

Should there be any real concern?

• The average number of daily cases among the locals in Singapore (in Singapore lingo the community cases) over the past 2 weeks is 9 cases

• For Malaysia, the average over the same period is 5

Maybe the plans to allow the cross border traffic through the causeway is OK.   

Appendix

 

Jul	No of local transmission			Causes of transmission
	L	F	Total
24	13	3	16	1F old folks cluster, 2F new cluster, 4L cluster due to contact with imported, 1 old folk cluster, 8L existing Sentosa cluster
23	4	2	6	2F detainees, 3L clusters in Kuching
22	7	1	8	1F pre-departure screen, 5L clusters, 2L screening
21	10	1	11	1F detainee, 7L clusters, 2L screening, 1L self-test
20	13	2	15	1F screening, 1F + 12L old folks home, 1L screen
19	8	3	11	3F different clusters, 1L old folks, 1L close contact, 1L self-test, 5L screen
18	4	1	5	1F pre-departure screen, 3L cluster, 1L screen
17	6	2	8	1F cluster, 1F pre-departure screen, 3L cluster, 3 screen
16	0	2	2	1F detention, 1F screen
15	3	1	4	1F sick, 1L contact, 2L screen
14	0	0	0
13	1	0	1	1L Novograd cluster
12	3	8	11	8F detainees, 1L contact, 2L sick
11	2	2	4	2F detainee, 1L sick, 1L screen
10	3	2	5	2F detainee, 3L screen

 Source:  MOH press releases

Note

1) Screening could be from SARI, flu-like screening, pre-surgical, workplace

2) L = locals

    F = foreigners

 

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PS: This blog is for me to better understand COVID 19 as this will impact my investments. If you are also into equities, follow me at i4value.asia

Disclaimer:  I am not an epidemiologist, healthcare worker, pharmacist, or staff in the Ministry of Health, but rather is someone with a strong interest in numerical analysis.  The content is an attempt to understand what is happening in the battle against COVID 19 from a data-based perspective. The opinions expressed here are based on information extracted from readily available public sources but I do not warrant its completeness or accuracy and should not be relied on as such.

Is the Old Folks Home spike a warning?

The recent news about the cluster among the old folks home in Kluang should be a wake-up call for MOH.

I think MOH has led its guard down as suddenly we have the 14 cases from the Kluang old folks home.

MOH said that the cluster was discovered after a 72-year-old man was brought dead on arrival to the hospital.  Following this, active case detection was initiated where

• 39 people were screened. 

• 14 tested positive (including the one that passed away)

• 18 were negative

• 7 are pending

The 14 comprised 12 elderly residents, one worker, and one family member.

The Kluang old folks home is a MOH failure as they have repeatedly told us that the old folks home is one of the targeted groups. 

The worrisome thing is that MOH said that they have tested this old folks' home before and found the residents to be negative.

MOH suspects that they old folks there could have been affected by “outside visitors” after the testing.

I find the explanation very disturbing because we all know that just because a person is tested negative one day does not mean that he would not get infected the next day.

MOH explanation seems to suggest that “their job is done once they have tested a particular group”.

I hope this is not the case. 

For 14 people in the target group to be found positive, it meant that they must have been infected at least a week ago.

If MOH had continued with its target testing programme, I think it would not have grown so large - the worst part is that the cluster was not discovered by the MOH testing programme.

MOH only found out when the patient was brought in dead on arrival.

We all know that the virus is still in Malaysia. 

Notwithstanding this, in my post on Tue, I said that if we are able to keep the number of sporadic cases below 30 a day, we can avoid an exponential growth and hence the second wave.

My confidence is because of 2 things

• MOH targeted testing and 

• MOH treatment policy.

MOH treatment policy is different from that in the US.  

In Malaysia, all those who have been tested positive are required to be hospitalized.  This is irrespective of whether the case is mild or the person is asymptomatic.

However, in the US, not everyone is hospitalized.  Remember Cuomo the TV host who got Covid-19?  He stayed at home when he got infected.    In the US only the very sick are hospitalized.

What this means is that the chances of the sick spreading it to the general public in the US is higher than in Malaysia.   

Given that many cases are mild or asymptomatic, the chances of the infected spreading to others is even worse. 

The MOH policy is actually a mechanism to isolate even mild and asymptomatic cases.

Let me give you an example. 

If a person is asymptomatic in Malaysia, and he begins to infect others who then seek treatment, the MOH contact tracing programme will eventually trace and quarantine even the asymptomatic.

So imagine this scenario

1. Index case A is sick but is asymptomatic.  So he can wander about freely

2. Then he infects B and C. 

 

3. If either B or C falls sick and seek treatment, MOH protocol will track A and all of  A, B and C will be isolated

4. You can ask what happens if even B or C are asymptomatic.  Then you can imagine them spreading it to another generation eg D, E, F

5. I think the likelihood is that eventually there will be a non-asymptomatic case who will seek treatment

6. When this happens, the whole lot from A to F will be isolated

7. The question is how many people in the chain (and/or how many generations) have to be infected before they are all rounded up

8. If the one detected is from the index case or the 1st generation, then the numbers involved in the round-up will be small

9. If the one detected is from the 2nd or 3rd generations, then more will be involved in the “round up”

10. So far in Jul, the numbers have been small. From the clusters that started in the first 19 days of Jul, the largest number seems to be 5

This is one leg of Malaysia’s “safety net”

The other leg is "targeted testing". MOH has said that it is more cost-effective to have targeted testing than mass testing of the public.

Over the past few months, MOH has identified 8 target groups for its “random targeted testing” programme

1. Tabligh

2. Tahfiz

3. EMCO areas

4. Markets

5. Old folks homes

6. Foreign workers

7. Healthcare staff

8. Existing clusters

The fact that the virus has been brought under control without the mass testing seems to validate MOH strategy.

But it was not foolproof.

Remember the spike in cases due to the detention centres?  This was a MOH testing failure.

The detention spike led MOH to include the prisons as one of the targeted groups.  So far there has not been any major outbreaks among the prisoners

The Kluang old folks' home cluster is another failure.

I am sure that if MOH had continuous testing of all the targeted groups, the cluster would not have gotten so big.

I hope this is seen as a warning to re-look at the testing plan.

In the context of testing, I have previously voiced the weaknesses in the reporting of the daily test numbers. It has not improved as the chart below shows.

We seem to have an average of 6,500 tests per day, but because of the failure to report daily, there are days with zero test and then the number jumps up when the backlog reports are reported. 

You would have thought that with a computerized system, the daily reporting cannot be such a difficult thing to solve.  Note that the SIMKA info system was introduced in mid-May. 

I worry that if such admin matters are so difficult to solve, what hope do we have that MOH will be able to identify new target groups and/or new sources of infection.  MOH slipped in the detention centre and now we have the old folks home.

I hope the lesson is quickly learned.

BTW, either the govt is not as "unrealistic" as I thought or someone in MOH is reading my blog.

Remember that I have been questioning the home quarantine plan for the returnees.  

The govt has changed its mind and now made it mandatory for all to be quarantined in the selected centres - but those quarantined have to pay for it.

The govt has changed its mind because people are not complying.  It seems there was one self-quarantined person who went out to eat.

I think govt policies have to take into consideration the "nature of the citizens".  I have no confidence that Malaysians are "disciplined" so we require mandatory rules for masks, social distancing and gathering.

If we look at how other countries have seen a resurgence in cases, we need "big brother" to be watching rather than hope that Malaysians will look after themselves.

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PS: This blog is for me to better understand COVID 19 as this will impact my investments. If you are also into equities, follow me at i4value.asia.

Disclaimer:  I am not an epidemiologist, healthcare worker, pharmacist, or staff in the Ministry of Health, but rather is someone with a strong interest in numerical analysis.  The content is an attempt to understand what is happening in the battle against COVID 19 from a data-based perspective. The opinions expressed here are based on information extracted from readily available public sources but I do not warrant its completeness or accuracy and should not be relied on as such.

Is there a way to avoid a second wave?

In my 1 Jul 2020 post,  I found out that of the world's top 50 countries in terms of the total number of Covid-19 cases,  there were 12 countries with a second wave.

How have these 12 countries performed over the last 2 weeks? 

• 5 are still experiencing an increased number of cases

• 3 countries are bringing it down

• 4 are at a plateau

 

Countries	Covid-19 status
US	Still increasing
Iran	Plateau
Turkey	Decreasing
Saudi Arabia	Decreasing
UAE	Decreasing
Kuwait	Plateau
Ukraine	Plateau
Portugal	Plateau
Philippines	Still increasing
Panana	Still increasing
Romania	Still increasing
Israel	Still increasing

The conclusion is that it is not so simple to control the virus.

The last time, I only looked at the top 50 countries.   

This time I decided to extend it to cover the No 51 to No 100 in terms of the total number of cases. For this group there are

• 13 countries with the second wave

• 14 countries still having an increasing number of cases

• 15 countries with decreasing number of cases

• 8 countries where the number of cases is at a plateau

The list of these countries is presented in the Appendix.

It is interesting to note that the number of countries with the second wave is about the same whether you look at the top 50 or the next 50 countries.

If you look at the statistics, about 1/4 of the top 100 countries in terms of the number of Covid-19 cases are facing a second wave.

So is there a way to avoid a second wave? 

I thought it was evident that as long as the virus has not been eliminated (I would imagine a country would require at least 14 to 21 continuous days of zero reported infection before it can conclude that the virus has been eliminated) there is always a chance that it would reappear. 

So it is not surprising to see second waves among those countries that did not eliminate the virus.

In this context I think we should not be surprised by the news that Australia or even Japan is facing a second wave - they never eliminated the virus ( as defined above,) before they opened up the economy.  The daily charts for both these countries show what I mean. 

Source: Worldodometer

Along the same lines, Malaysia is in the same boat as we never eliminated the virus. We just got the numbers to be low when we opened up the economy,. 

So will we have a second wave like those of Japan or Australia?

I don’t think so because, by definition, the second wave is the result of another exponential growth. 

As long as the number of cases in Malaysia can be kept below the exponential trigger point, we can avoid a second wave.   

I have not seen any number from the authorities about this trigger point, but I have in my 2 May 2020 post I estimated that if we have less than 30 daily cases (excluding the imported), we safe from exponential growth. 

These 30 cases should be sporadic cases ie not from one or two clusters.  By sporadic cases, I mean that we have not been able to identify the cause/source of the infection.  

In this context, the daily numbers for Jul to date have been below this 30-cases threshold.

But more importantly, a large part of our Jul numbers came from clusters.  Although as of today we have 19 active clusters, 13 of them actually started in Jul ie the index case was reported in Jul.

This meant that in Jul we actually had 13 index cases that spread it to 23 others so far (the test results for some of the clusters are still pending).  

• 4 of the index cases were identified as being infected when overseas

• Several were identified as part of MOH “critical group” testing

So not only are the numbers small, MOH is still testing to identify cases before they have a chance to spread further.

Apart from testing, what else do we need to do?

Prevent the virus from coming into the country.  I have already voiced my concern about our self-quarantine procedures.  

I was thus happy to note the 16 Jul media report that MOH is reconsidering the possibility of placing returnees from high-risk areas, either in hotels or quarantine centres.

At a press conference on Thursday (July 16), the DG of MOH added that those coming to the country must take a test before boarding the plane.

Now MAS has this travel advisory on its website

"Effective 20 July 2020, all Malaysian nationals and foreigners entering Malaysia through International Arrivals are required to undergo a mandatory Polymerase Chain Reaction (PCR) COVID-19 test,  three days prior to the date of departure. Those with negative results will be allowed entry into Malaysia. The result or medical certificate issued must be in English"

Conclusion - how do we prevent a second wave if we have yet to eliminate the virus?

• continue the "random" testing so that we can identify and isolate cases before they have a chance to spread further.  

• control imported cases

I would like to add "social distancing" and wearing masks but I think the reality is that in Malaysia, most of us have not been following the social distancing guidelines although many still wear masks.  

My view is that as long as the number of cases out there is very small, we can get away with it.  But the moment we have a surge, I think we need to be strict about social distancing. 

Appendix:  Countries in the No 51 to No 100 ranked position in terms of the total number of Covid-19 cases. 

A) Those with the 2nd wave: 

1. Romania - No 46
2. Japan - No 57
3. Algeria - No 58
4. Serbia - No 60
5. Morocco - No 63
6. Chechia - No 67
7. Australia - No 71
8. North Macedonia - No 77
9. Bulgaria - No 81
10. Luxembourg - No 93
11. Djibouti - No 94
12. Croatia - No 96
13. Paraguay - No 100

Note:  The No refers to the ranking as per Worldodometer

B) Those with increasing Covid-19 cases

1. Honduras

2. Ghana

3. Azerbaijan

4. Kyrgyzstan

5. Uzbekistan

6. Kenya

7. Venezuela

8. El Salvador

9. Costa Rica

10. Bulgaria

11. West Bank and Gaza

12. Bosnia and Herzegovina

13. Madagascar

14. Albania

C) Those with decreasing Covid-19 cases

1. Switzerland

2. Ireland

3. Austria

4. Nepal

5. South Korea

6. Denmark

7. Sudan

8. Norway

9. Malaysia

10. Finland

11. Haiti

12. Tajikistan

13. Mauritania

14. The Central African Republic

15. Hungary

D) Those with Covid-19 at a plateau

1. Moldova

2. Cameroon

3. Ethiopia

4. Senegal

5. Congo

6. Guinea

7. Gabon

8. Greece

Note:  I referred to the John Hopkins Coronavirus Resource Centre daily case chart to identify the virus trajectory (eg declining, the second wave).  However, I referred to Worldodometer to identify the top 100 countries. I noticed that there were 2 countries in the John Hopkins database ( Cote d'Ivoire and Kosovo) that are not covered by Worldodometer. 

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Be fearless to get more to Stay Safe, Share this Blog

PS: This blog is for me to better understand COVID 19 as this will impact my investments. If you are also into equities, follow me at i4value.asia.

Disclaimer:  I am not an epidemiologist, healthcare worker, pharmacist, or staff in the Ministry of Health, but rather is someone with a strong interest in numerical analysis.  The content is an attempt to understand what is happening in the battle against COVID 19 from a data-based perspective. The opinions expressed here are based on information extracted from readily available public sources but I do not warrant its completeness or accuracy and should not be relied on as such.