As the numbers of new COVID-19 infections continue to rise in Malaysia, I would like to make some comments on how we can help to protect ourselves and others, and how our assessment of risk impacts these decisions.
But first, why should you take any notice of what I say? My credentials are: a BSc Hons degree in Pharmacology (Bristol University, UK); a PhD degree in Biochemistry (Bath University, UK); 12 years as an industrial pharmacology in UK (for Glaxo Group Research, now known as GSK); and 24 years as an academic pharmacologist teaching medical students, pharmacy students, training postgraduate students, and undertaking research projects (Chinese University of Hong Kong, CUHK).
In all my professional work I spent many hours in safety committees of all varieties. And there was always one issue common to all scenarios: the ‘lack of compliance’. If the message of the safety committee isn’t clear, consistent, logical, and readily understandable, compliance will be low. And if the committee members do not comply with their own recommendations, then compliance will be low.
Risk Assessment
Just before I retired from CUHK, I tried to get a course on risk assessment included as part of the general education program for all university students, because it impacts our lives in so many ways. The simplest example of risk assessment is seen when making investment decisions. When we are young, we are considered ‘risk tolerant’. High risk investments may yield bigger profits, and should the investments fail, we still have time to recoup our losses; all is not lost. As we approach retirement we become ‘risk averse’ because if our investment fail, we have no time or opportunity to work and recoup our losses. So older people tend to put their savings into lower yielding but safer investment plans. Our ability to accept risk is dependent on our life circumstances.
What does this have to do with COVID-19? There are several issues we can address to help reduce the chance of infection and death: (1) vaccination, (2) social distancing, (3) face mask wearing, and (4) maintaining good health status. Our ability to get vaccinated is totally out of our control as access to vaccines is controlled by the government, but we can do something about the other three issues. At least we can if we have the money to do so, since these three issues are not readily controllable by the poorest in our communities.
(1) Vaccination
The government does not provide much in the way of information/advice about their vaccination program for residents who cannot read Bahasa Melayu. So I am going to present some information here which I hope gives you a better understanding of matters relevant to those of us resident in Malaysia today.
The recent controversy about the safety of the AstraZeneca vaccine has highlighted how the general public, and our government officials, do not understand drug development and the assessment of risk. When new therapeutics are approved for general use, they will only have been tested in some thousands of patients. So they are closely monitored for rare adverse events, because as they are rare, they will not been detected until the new therapeutic is more widely used. Most government drug regulatory authorities have the power to fast track the approval of new therapeutics in times of national emergencies. They inherently understand that they cannot wait for years while all safety tests are completed, they have to act fast in the case of a pandemic such as COVID-19. It is not too different from testing new drugs for otherwise incurable forms of cancer. If a cancer patient has tried every option and is near death, they will accept the risk of trying a new untested therapeutic because, if it fails, the outcome is no different to the patient. At this level, we intuitively understand risk assessment.
So why did everyone panic over the reports of the blood clots apparently caused by the AstraZeneca vaccine? In part it is because the general public would not be aware of how common/uncommon blood clots are. They would not know that the risk of blood clots for smokers is 0.18% compared to just 0.0004% for taking this vaccine. That means that the risk of having a blood clot because of smoking is 450-times higher that the risk created by taking the AstraZeneca vaccine. More importantly the risk of blood clots from COVID-19 infection is 16.5%, that is 41,250-times more! Put this way, why wouldn’t you take the AstraZeneca vaccine?
The justifiable answer comes down to the influence of other factors in our assessment of risk. The incidence of blood clots from the vaccine was highest in young women, while the incidence of virus-induced fatalities is greatest in the over 60’s. So, in circumstances where the level of COVID-19 infection around you is relatively low and well controlled, and you have a variety of vaccines available for your population, then use the AstraZeneca vaccine for the senior age group and use an alternative vaccine, or none at all, for the younger age group. If however, infections rates are out of control and ICU beds are full, vaccinate your population with whatever source of vaccine you have available! But let’s remember to put all this into perspective. Your chances of dying with coronavirus are higher than a serious side effect from vaccination, especially as your age increases.
As of 1st April 2021, only 31.4% of the adult population of Malaysia has registered for COVID-19 vaccination, and only just over 2% have received their first dose. Malaysia’s slow procurement of vaccine supplies is a serious problem, so this is the time to educate the population about vaccination and get those registration numbers up to 80%, ready for when vaccine supplies appear. This topic has been well articulated in an article in ‘The Edge Markets’ so do check out the link. Just remember that vaccines do not prevent you getting infected, they simply help your body fight an infection more efficiently. This means that you are less likely to require hospital care, and you are less likely to pass the infection on to others. This is why Malaysia’s vaccination slogan is “Lindung Diri, Lindung Semua” or "Protect Yourself, Protect All”.
(2) Social Distancing
We are now more aware that the principal means of transmission of COVID-19 is by airborne droplets. So, maintaining space between ourselves and others should be a relatively simple procedure. But in high density city living, and in large family units, keeping our distance is not always possible. The advised safe distance is confusingly inconsistent, so perhaps the most valuable help comes from the WHO website which is full of useful information.
The instruction to Stay at Home, which was strongly played during MCO 1.0, seems to be missing from the current instructions in MCO 3.0. But that does not mean we should not do as much as possible to reduce close contact with others. The possibility of asymptomatic transfer of infection is also currently underplayed, perhaps because it highlights the lack of community testing to determine potential hotspots of infection. So, there are suggestions that for family groups with at least one member being in daily contact with many others, then that person should even wear a face mask at home to protect their family members from possible infection from an asymptomatic host. (The mask worn outside should be removed for disposal/washing and a fresh mask worn indoors.) Again, this is one issue where the individual group needs to make their own risk assessment.
(3) Face Mask Wearing
Our decision to (1) wear a face mask, and (2) wear it properly, is unconsciously determined by the balance of our own assessment of risk of catching COVID-19 and of peer pressure. The influence of peer pressure is easy to understand. If everyone around us is not wearing a face mask, we will feel uncomfortable doing so and so might remove our mask in order to fit in. We also might feel uncomfortable asking a more ‘senior’ person to put on their mask, for obvious reasons.
However, the most basic safety measure in this pandemic is to wear a mask. I find it frustrating to see people wearing face masks incorrectly, and to see senior members of the community not wearing face masks at all! The behaviour of hanging your mask under your chin indirectly leads to greater risk of transferring the coronavirus into the mouth or nose. Back in March 2020 when I started collating information in English about COVID-19 in Malaysia (see Life during the COVID-19 outbreak), the advice was not to wear a mask unless you had COVID-19. This advice was presented because face masks are successful if used correctly (as used by trained medical professionals) but are hazardous when used incorrectly (by the general public). Circumstances have changed now and everyone is advised to wear a face mask of some sort. And on 7th May, the CDC updated its advice, putting greater emphasis on airborne transmission as the primary means of infection.
To find out the best mask to wear, I would recommend you go to the CDC website and the page on Your Guide to Masks. Personally, I find the blue surgical masks plain annoying as they slip up my face and obscure my glasses, and are uncomfortable. I had to wear these every day at work during the SARS outbreak in Hong Kong, but thankfully that period was relatively short lived. We are now getting to the stage where wearing face masks will be something we need to do in public spaces for years to come. I am also concerned that, since these surgical masks should be replaced every day, I am considerably increasing the amount of non-biodegradable waste in an already heavily polluted world. So my preference is for washable fabric 3-ply face masks. And, as recommended by the CDC, I could wear a surgical mask under a fabric mask if the risk of infection is considered very high. So, I have recently purchased some fabric face masks from the Gibbon Conservation Society (see their FB page) and they are very comfortable to wear for extended periods of time. [Information for ordering these masks is from this link]. The photo at the top of the page shows Lawrence wearing one such mask. (N.B. The current (June 2021) advice for those going to the convention centre in Johor Bahru for their AstraZeneca jobs, is wear a surgical mask under a fabric mask.)
(4) Maintaining Good Health Status
It was clear early on in the pandemic that people with underlying health issues would be more seriously affected by COVID-19 than otherwise healthy individuals. So this is just a gentle reminder to maintain a healthy weight, and have your blood pressure and blood glucose levels regularly monitored and corrected as necessary. And of course exercies when safe to do so. Maybe we should also encourage food vendors to decrease the automatic inclusion of sugar in our drinks!
So, how do we assess risk-benefit ratios during a pandemic?
1) Know what’s out there! Keep up to date with the situation around you. You can keep track of Covid-19 cases in Malaysia with this website... https://covid19.place/MY/en-US/06-37-pm-15-01-2021. And use the Hotspot button on the MySejahtera App to tell you of case numbers within a 1km radius from your current location in the last 14 days.
2) Use the MySejahtera App homepage for the latest information, and try to interpret the pictograms as best as possible. You will have to option to use English when setting up your app and registering for the vaccine, but none of the daily reports or general annoucements will be available in English.
3) Pay attention to advice from the WHO (World Health Organization) and the CDC (Centers for Disease Control and Prevention).
4) Use the information I have presented here as a prod to think about your own situation, and as the basis for discussion. Consider all the data rationally because a risk-benefit ratio is not a one-size-fits-all solution. It is personal to your circumstances.
Human beings are, by their very nature, social beings. So learn how to maintain your social network in as safe a way as possible.
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