What happened to the second wave?

I have not been talking about Covid-19 mysteries for some time.

This time, I think we have a real mystery. It is about the coming third wave. 

I am very confused by what I saw on TV as well as what the DG of MOH was quoted as saying by leading media companies.

Both the TV and newspapers said that there is a possibility of a 3rd wave if we don’t follow the SOP.

This third wave story was carried by Star, NST, Edge and even MSN News a few days ago.

I have always thought that there was only one wave so far. 

If you look at the chart of the daily number of cases in Malaysia since 1st Feb as shown below, you can see one large “hump” in March/April. 

If I plot the 7 days moving average line (as denoted by 7MA in the chart), you can clearly see one large wave in Mac/April.  This is followed by several small “wavelets”.  

If the govt is calling these small "wavelets" as “waves” then we already have 4 waves based on this definition. 

Not satisfied, I decided to plot at 14 days moving ave as shown in the chart below.

Well maybe based on the 14 days moving average, we can say that we had 2 waves - one in April and the other smaller one in June.

We can also see that the 14 days moving average is currently turning upwards a bit. 

If this is the govt interpretation, public relations messaging is very wrong.  When was the second wave officially announced then? 

If you do a Google search for “Malaysia Covid-19 second wave”, you will find the following

• Malay Mail 18 Jul:  The Health Ministry is actively implementing the ‘Avoid Close Contact’ campaign, as a step to prevent a second wave of Covid-19 outbreak in the country, Minister Datuk Seri Dr. Adham Baba said.

• NST 21 Jul:  Malaysian Public Health Physicians' Association president Datuk Dr Zainal Ariffin Omar said the emergence of new cases in Malaysia was alarming and, if not properly handled, might lead to a second wave

• Code Blue 22 Jul: The Malaysian Health Coalition (MHC) echoes the Prime Minister in urging the Rakyat to stay vigilant and abide by precautions and standard operating procedures (SOP) to prevent a second wave of Covid-19 in Malaysia. 

As you can see, about 10 days ago, people in the know were talking about a coming second wave.

Then a week or two later (and no major spike in cases during this period) no less an authoritative figure like the DG of MOH is talking of a third wave.

Dont you think it is mysterious?

The first wave was caused by the Tabligh event while the June one is due to the detention centre.

Even if we take this as what the govt is referring when they suggested that we already had 2 waves, I still don’t see the argument that we will have the 3rd wave if we don’t comply with the SOP

We all know why we had the first wave.  

• The people attending the Tabligh event did not social distance or wear masks

• There were lousy records of who attended making contact tracing difficult

So a few things happened.  People got infected during the function. These index cases went home and infected their contacts. Because of slow contact tracing, the first generation infected other generations and the whole thing snowballed.

As for the second wave at the detention centre, it spiked because it was not possible to social distance. I don’t know whether they were provided with masks during detention. By the time the authorities found out about the first few index cases, it had already spread and thus we had the spike

The common thread among these 2 waves are

• Somehow a significant group of index cases gathered together

• There were many in the gathering who did not/could not social distance.

• Very likely those who gathered did not wear masks

Were these all the people’s fault?

I don’t want to get into the debate on who allowed the Tabligh gathering.

But for the detention wave, it was certainly the govt fault for keeping people close together and maybe not giving them masks in such close quarters. I could possibly make a case of the govt fault for not testing the detainees (before the outbreak).

Now to come back to the question of the coming wave.

If you look at my past posts, I have argued that we currently do not have large groups of infected people walking around.  Also except for Sarawak, the cases do not seem to be from one particular area. 

So the infections are many localized cases.  I think these should be within our means to contact trace and isolate before it grows exponentially.

If the number of cases is few and widely spread, it means that most of the places in the country don’t have the virus (OK, this should exclude Sarawak).

For those places without the virus, I think we can disregard social distancing and wearing a face mask without any negative impact.

I am not sure how many saw Dr Fauci on TV on recently.  He was asked about the opening of schools in the US.  He said that there are different levels of intensity in the country in terms of the number of cases.

So for those places with negligible numbers, people don’t have to be concerned about children going to schools.

The analogy applies to Malaysia.  

For those places with hardly any virus, the enforcement of masks and/or social distancing is a waste of resources.

If you accept my argument above that we are not in any imminent danger of another wave, why are the authorities raising this 3rd wave and another round of MCO?

• Is there under-reporting of the number of cases?

• Are there non-health reasons for talking about another MCO?

What happened to the 2nd wave?

Let me know if you have other clues that can solve this mystery. 

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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.

The numbers are less frightening than you think.

Over the last 7 days (21 to 28 July) we had 5 days with a double-digit number of daily cases. The first impression is that the numbers look high.

But I want to offer an alternative way of looking at the numbers.

As of 28 Jul, there are 27 active clusters in the country (Source: Malaysiakini) 

• I think MOH classifies a cluster as non-active when there are no more cases linked to the cluster for a continuous period of time. It could be at least 4 weeks

• An active cluster means that we are likely to see more persons in contact with the respective index cases falling sick. 

The 27 clusters can be categories as follows

Clusters during the past 7 days	No of clusters	No of cases during the past 7 days
Already existing	19	42
New clusters	8	35
Total	27	77

When you look at the table, you can see

• 19 clusters at the start of the 7 days period.  

• 8 which were identified during the past 7 days

When you analyze the 27 clusters

• 3 of them (Bukit Jalil detention centre, Sepang detention centre and cleaning company) started in May

• 12 had index cases who came to Malaysia from overseas ie, not local transmission

• The balance started in Jul

So you can conclude that in the month of Jul, there were just 12 index cases that got COVID from some yet to be determined source in the country.  Then those unfortunate to be in contact with these 12 index cases got sick.

I think that 12 new unknown sources of infection over a one month period doesn’t sound so alarming.  

It meant that the asymptomatic cases in the country which infected them looks manageable.

The other issue with the statistics is that the number of cases within each cluster is not the same. 

• The Sentosa cluster (an existing one at the start of the 7days period) had 24 new cases during the past 7 days.  1026 people related to this cluster have been tested and 107 tests are still pending.  So we may still see some cases for this cluster.   The cause of the index infection is still under investigation. 

• The Bukit Tiram cluster (a new cluster during the past 7 days) had 9 new cases.  The index case came to the country from the Philippines. 

So some clusters had more aggressive spreader-index ie the super spreader.

In terms of risk, not only are the number of locally transmitted index cases low, they are concentrated in Sarawak. 

Of the 27 clusters, 8 are in Sarawak.  If you consider that of the 27 clusters, 12 originated from overseas, the 8 in Sarawak becomes more alarming. 

I think this is why the govt is imposing some “mild” lockdown in Kuching starting 1st Aug.  Kuching has been designated a red zone (with > 40 cases) and some of the neighbouring areas are designated as yellow zones (< 40 cases).

What I don’t understand is why delay the start of the “restrictions”.  If the history of the virus has anything to teach us, it is that any delay will lead to more serious consequences.

If the numbers are already alarming to consider more restrictive measures, we should not wait.

We should watch Sarawak as this is the first red zone after the end of the MCO.  

Remember what Dr. Fauci said about face mask and social distancing? That they can control the virus without a shutdown.

I was looking for evidence of this and came across a Lancet article.

The authors investigated the effects of physical distance, face masks, and eye protection on virus transmission.  

Their findings were

• Transmission of viruses was lower with the physical distancing of 1 m or more. Protection was increased as the distance was lengthened 

• Face mask use could result in a large reduction in risk of infection with stronger associations with N95 or similar respirators compared with disposable surgical masks or similar

• Eye protection also was associated with less infection

When you look at the study, I think we would be an idiot if we have another shutdown.

• We have low cases ie easier to contact trace and isolate

• There is generally no issue about wearing a face mask

• Maybe our social distancing message can be improved

Let's look at the latest face mask position based on the YouGov survey (around the 3rd week of Jul).  I only picked out the top 5 and the bottom 5 of the countries surveyed

Country	% of people who said that they wear face masks when in public places (YouGov)	No of Covid-19 cases per m population (Worldodometer)
Singapore	92 %	8,803
Thailand	88 %	47
Spain	88 %	7,008
Hong Kong	86 %	400
Malaysia	85 %	276
UK	38 %	4,428
Australia	20 %	610
Finland	7%	1,338
Sweden	6 %	7,868
Denmark	4 %	2,343

You will be surprised by the US at 74 %.  A month ago, it was below 70%.

I was hoping to find that those countries with a high % of people wearing a face mask would have low cases but Singapore and Spain made this difficult.

Of course in Singapore, the majority of the cases were from the migrant workers and I think the face mask would not help as they are being infected in the dorms.  

Anyway, my main points are

• the number of daily cases is not as alarming as my first impression

• there is evidence that wearing a face mask can help control the virus.  I think the US will be the first large scale proof of this

• we will be idiots if we resort to another lockdown. I think Sarawak will be our first test case of regional "restriction" to control the virus without a national lockdown.  I will be disappointed if this does not work. 

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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.

Is there any need to worry about Covid-19?

If you look at the number of daily cases in Malaysia over the past 2 weeks, you can be forgiven if you think that the number of cases seems to be increasing.

I think the danger of listening to the US news and about what is happening in other countries can sometimes confuse you about what is happening in Malaysia. 

I know that the virus is hard to eliminate.  Just a few days ago, I heard the news that Vietnam had its first case after 100 days of zero cases.  

Should we be worried about what is happening in Malaysia as we seem to be having about 10 to 20 daily cases recently?

I think we should look at the 10 to 20 daily cases in 2 context

• Are the cases increasing at a rate that will lead to another round of MCO?

• Are the 10 to 20 cases deadly to our daily lives?

Another MCO

The MCO was done at a great cost to the economy and while there have been rumblings by the authorities that we can have another shutdown if we don’t follow the SOP, I would be very surprised if we resort to this.

If you look at the chart, there are imported and local transmissions.

We cannot avoid the imported ones if we continue to allow Malaysians to return and/or allow certain foreigners to come to Malaysia.

As long as we have strict quarantine measures to control the incoming traffic, even if there are cases among them, I am confident that it will not spread to the locals.

So we only need to be worried about the local transmission.

I have previously shown that if it is only 10 to 20 cases and the number does not increase exponentially, we are safe from a second wave.

This means there is no reason for the MCO

.

Besides, if you look at the current cases, many are due to clusters and they seem to be mainly in Sarawak.

The clusters are proof that our contact tracing and isolation program is working. As long as the number of cases doesn’t overwhelm this system, we should be ok

  

This is even if the contact tracing is slow such that we are only able to isolate all after they have gone into the second generation.  The number of generations is not the main point. The critical point is to catch all of them.

The second point is that if the majority of the cases are located in a particular district, there is the option of having the MCO only for the particular district.  

There is no reason for a national shutdown.  This is the current Australian practice to control the second wave and I think it is a good one. 

Finally, there seems to be a “new” option based on what Dr. Fauci said recently.  I saw him on TV to say that the US doesn’t need to shut down if people social distance and wear masks.  

In the US, certain areas were reported to have positivity rates of 20%.  This means that the virus is widely spread in the community. 

So if it is possible to control the transmission with such a high positivity rate without a lockdown, there is no reason for another MCO in Malaysia. Our current positivity rate is around 1%.  OK, course we have yet to see whether Dr. Fauci's idea will actually work in the US. 

The conclusion is that the virus in Malaysia is at a rate where we can easily cope with both from the contact tracing and treatment perspectives.

Unless the surge is such that it would overwhelm it, we should not be unduly alarmed by the current numbers. 

Is it deadly?

The other point about our numbers is that we should look at it in comparison with other illnesses in the country. 

As of 27 July 2020, Malaysia had 8,904 Covid-19 cases with 124 deaths.  

While I don’t want to play down the significance of Covid-19, it is useful to look at the comparative incidence of sickness and mortality in the country. 

The table below shows the impact of Covid-19 compared to the other major causes of deaths in Malaysia.  

• There are more people who died in transport accidents in 2018 c/w Covid-19. 

• The current total Covid-19 cases are equivalent to 275 cases per million population. There are more who got TB or Dengue 

You can see that we have "accepted" the risk of other illnesses without having to shut down the economy.   Nobody said we should cut down the number of cars due to the high transport accidents deaths. 

There is an argument for learning to live with Covid-19 like how we have lived with Dengue, TB and HIV. 

Causes	Reference year	Cases per million population	Deaths per million population	Source
Covid-19	2020	275	5	Worldodometer
Cancer	2016/18	1,370           (c)	592	Malaysian National Cancer Registry
Ischaemic heart disease	2018		590           (a)	Statistics Dept
Pneumonia	2018		450            (b)	Statistics Dept
Cerebrovascular disease	2018		300            (b)	Statistics Dept
Transport accidents	2018	17,400         (d)	140           (b)	Statistics Dept
Dengue	2016	3,181		MOH Health at a glance 2018
HIV	2016	107		MOH Health at a glance 2018
Malaria	2016	73		MOH Health at a glance 2018
TB	2016	813		MOH Health at a glance 2018

 Notes

a) 18,627 deaths reported out of 31.53 million population

b) These were derived based on 11.8 % (Pneumonia), 7.8 % (Cerebrovascular) and 3.7 % (accidents) c/w 15.6 % for the Ischaemic heart disease.

c) Globalcan 2018

d) 548,598 road accidents were reported to the Police

Of course, this “not so deadly” comparison was the argument that Fox News made at the start of Covid-19 in the US ie why fuss when we don’t really fuss about the flu.

I think that at that point in time, Covid-19 was still new and there was much that the world did not know about Covid-19.  

Today we know much more.  

If you look at the mortality is Malaysia, it is not as serious as what was thought initially. 

Of course, Covid-19 is more contagious and more deadly than the normal flu.

And you will argue that the comparative number is low for Covid-19 because we had the MCO to control it.  I suspect that without the MCO, it may be many times larger.

Having said, this, now that we have brought it under control, there is also no need to overreact and panic ourselves.

We know social distancing, wearing masks and public hygiene can prevent the spread.

It will not eliminate it. But I think we have to accept that the virus is here and the people's job is to keep the numbers low so that economic activities can resume.

If you look at the table, we have learned to live with Dengue,  cancer, and TB.  

We just need to learn to live with Covid-19  ie have it as part of the low risk in our daily lives.  I think the number of cases will never be as high as traffic accidents.

Technically, President Trump was right to think that the virus is not as serious as what the doctors are saying.  The mistake he made was not to control it to a level where they could live with it.  He allowed it to get to a point where the mortality became large.

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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.