By Dato' Dr Amar-Singh HSS

Yes you read that title right—it is intentionally written in that way to get your attention. Many Malaysians have started to become complacent as the number of cases have come down. So now our risk of getting infected by the coronavirus is going up.

We are all grateful that we are coming out of the first wave of the COVID-19 pandemic in Malaysia. It is a testament to the very hard work of the Public Health arm of the Ministry of Health (MOH), the dedication of doctors and nurses in wards and clinics, all the police and armed force personnel, and the effect of our strict movement control order (MCO).

However with the relaxation of the MCO we see, in many parts of the country, some people flouting all the key principles of COVID-19 prevention that have been drilled into all of us these past 2–3 months. There has been a disregard for safe physical distancing, hand hygiene, safe mask use and group gatherings. There are videos and reports of crowded mass transport, birthday parties, busy food shopping locations (akin to Ramadan bazaars), long queues outside some shops, masks being touched often and noses exposed, disposable masks being dried for reuse, thousands of migrants being rounded up and transported in mass groups, etc.

Since so many Malaysians seem very keen to get infected, allow me to suggest five easy ways to increase your risk of getting infected by COVID-19:

1. Don't keep a safe physical distance from others. Talk often to other people and given them hugs. Meeting people who have respiratory illnesses is particularly useful.

2. Don't use an alcohol based hand disinfectant and don't wash your hands often. Remember to touch as many surfaces as you can when outside the home and then remember to touch your face.

3. Don't wear a mask when you leave the home. Also touch and adjust your mask often when outside the home. Pull your mask up and down often or keep your nose exposed. Talk with your hand phone to your face when wearing a mask.

4. Stay for long periods in air-conditioned environments with as many persons as possible. Packed lifts, busy restaurants, crowded buses or LRT and small/cramp offices and factories are all very useful places to pick up the virus. In addition plan group gatherings like birthday parties, religious/cultural meetings, conferences, etc.

5. Make sure your organization, company or office does NOT have a detailed COVID-19 prevention plan (SOP) in place. Just continue working or behaving as you used to before the pandemic and you will easily pick-up the virus.

I hope you realize that the suggestions given above are written as sarcasm, to push us into doing the exact opposite.

We have had time to learn but some of us do not seem to have understood the messages and reality. We have had time to prepare to return to work but some of us seem to be at a loss as what to do next. There has been much information and guidelines offered but meaningful usage seem limited.

With the relaxation of the MCO we need to maintain a heightened, an even increased vigilance so as not to rapidly enter a second wave that may be even larger. This pandemic is just starting out and we are in it for the long haul.

For those who have been lulled into complacency, thinking everything is OK, kindly consider the following data.

Our reported numbers in Malaysia are only 6,742 identified cases. But we know that we miss a large number of cases, most countries do.

As an example, a useful study from Brunei using antibody tests to do a nationwide random community survey showed that 6 out of 527 were positive, i.e. a 1.1% positivity (95% CI for this sample are 0.46 to 2.59%). This offers an estimate of the rate of COVID-19 infection among the community in that country. The official number of COVID-19 reported cases in Brunei is only 141. But if 1% have been infected (as the study suggests), then for their population of 429,000 people, the true number of cases is about 4,290. This means that for every one case they identified they missed 30 infected persons.

So what about Malaysia? MOH has shared the following data:

1. Many hospitals are testing patients before surgery to protect health staff. These are people with no known risk of COVID-19. Out of 8,528 tested 6 were positive, i.e. a 0.07% positivity (95% CI for this sample is 0.03 to 0.16%).

2. Selangor, which has been doing community screening, showed that 10 out of 5,433 individuals tested were positive for COVID-19, i.e. a 0.18% positivity (95% CI for this sample is 0.09 to 0.35%).

3. Screening at several markets showed that of 25,034 persons tested 183 were positive, i.e. a 0.73% positivity (95% CI for this sample is 0.63 to 0.85%).

4. Migrant workers screened showed that 1,132 were found positive out of 24,125 tested, i.e. a 4.7% positivity (95% CI for this sample is 4.43 to 4.97%).

5. Finally, Malaysians returning from overseas who are tested for COVID-19, have a positivity rate of just under 1%.

From all this data it is reasonable to assume that at least 0.1% of the population is positive currently. This works up to at least 32,000 cases in the country. In case you find this ‘alarming' remember that if we used our coronavirus deaths (109) and assume a case fatality rate (CFR) of 1% (i.e. for every 100 cases there is 1 death) then there were 10,900 cases 4–6 weeks ago in Malaysia (this number will be doubled if we use the lower CFR that is being suggested international rate of 0.5%). Remember all this was happening during our MCO period and rates will only increase with the current relaxed MCO phase.

Hence with the continued behavior of some Malaysians that allows the virus to spread, the second wave is coming, not IF but WHEN. The second wave will be from asymptomatic and mildly symptomatic individuals (80% of all cases) and happen as the public returns to work and other activities. The second wave is the one to be concerned with as it comes from within our country and is spread out all over the nation. Please do not allow our low numbers to lull you into complacency.

The MCO has bought us precious time despite the enormous pain and sacrifice many have experienced. It has decreased the first wave of the pandemic but in doing so pushed the rest of the outbreak to a later date. We must not squander this opportunity and need every Malaysian to take personal action and behavior change to keep COVID-19 at a low rate while we look to long term solutions to be generated.

(Dato' Dr Amar-Singh HSS is a Senior Consultant Pediatrician.)