Short Communication
Characteristics of the COVID-19 epidemic and control measures to curb transmission in Malaysia
Chris Fook Sheng Ng
a,*, Xerxes T. Seposo
a, Meng Ling Moi
a,b,
Muhammad Abdul Basit Ahmad Tajudin
a, Lina Madaniyazi
a,b, Mazrura Sahani
caSchoolofTropicalMedicineandGlobalHealth,NagasakiUniversity,Nagasaki,Japan
bInstituteofTropicalMedicine,NagasakiUniversity,Nagasaki,Japan
cFacultyofHealthSciences,UniversitiKebangsaanMalaysia,KualaLumpur,Malaysia
ARTICLE INFO
Articlehistory:
Received7May2020
Receivedinrevisedform9October2020 Accepted9October2020
Keywords:
Coronavirus COVID-19
Preventionandcontrol Reproductionnumber Transmission
ABSTRACT
ThefirstwaveofCOVID-19epidemicbeganinlateJanuaryinMalaysiaandendedwithaverysmallsize.
ThesecondwaveofinfectionsbrokeoutinlateFebruaryandgrewrapidlyinthefirst3weeks.Authorities inthecountryrespondedquicklywithaseriesofcontrolstrategiescollectivelyknownastheMovement ControlOrder(MCO)withdifferentlevelsofintensitymatchingtheprogressionoftheepidemic.We examinedthecharacteristicsofthesecondwaveanddiscussedthekeycontrolstrategiesimplementedin thecountry.Inthesecondwave,theepidemicdoubledinsizeevery3.8days(95%confidenceinterval:
3.3,4.5)inthefirstmonthanddecayedslowlyafterthatwithahalvingtimeofapproximately3weeks.
Thetime-varyingreproductionnumberRtpeakedat3.1(95%credibleinterval:2.7,3.5)inthe3rdweek, declinedsharplythereafterandstayedbelow1inthelast3weeksofApril,indicatinglowtransmissibility approximately3weeksaftertheMCO.TheexperienceofMalaysiasuggeststhatadaptivetriggeringof distancingpoliciescombinedwithapopulation-widemovementcontrolmeasurecanbeeffectivein suppressingtransmissionandpreventingarebound.
©2020TheAuthor(s).PublishedbyElsevierLtdonbehalfofInternationalSocietyforInfectiousDiseases.
ThisisanopenaccessarticleundertheCCBY-NC-NDlicense(http://creativecommons.org/licenses/by-nc- nd/4.0/).
Introduction
The first case of coronavirus disease 2019 (COVID-19) was confirmedinMalaysiaonJanuary25,2020,markingthefirstwave ofinfectioninthecountrythatlastedforabout3weeks(Ministry ofHealthMalaysia(MOH,2020).Thetotalnumberofcaseswas low,with22confirmedinfections,20ofwhichwereimported,and nofatalities.
AsecondwavebrokeoutonFebruary27after11daysofnonew cases.OnMarch11,aneighboringcountry,Brunei,traceditsfirst infectiontoalargereligiousgatheringinKualaLumpur,Malaysia, between February 27 and March 1 attended by about 14,500 participants.Approximately2weeksafterthegatheringonMarch 15,Malaysiarecordedthefirstthree-digitjumpinadaywith190 new cases. The next day, authorities announced a nationwide MovementControlOrder(MCO),asoftcordonsanitaireorpartial lockdownthatwentintoeffectonMarch18toreducesocialmixing
(MinistryofHealthMalaysia(MOH,2020).Thiswasfollowedbya stricter version called the enhanced MCO, an adaptive policy implemented indefinitely following March 27 to contain large epidemicclusters.Following thedecline ofcases,theMCOwas subsequently relaxedand replaced bya Conditional Movement ControlOrder(CMCO)onMay4,and furtherrelaxed underthe RecoveryMovementControlOrder(RMCO)onJune10.
Here,wedescribethecharacteristicsofthesecondwaveofthe COVID-19epidemicinthecountryandrecountthemajorcontrol strategies.
Methods
Refertothesupplementarymaterial.
Results
BytheendofAugust,therewere9340confirmedcaseswitha recoveryrateof96.9%.Importedcasesmadeup8.8%(826),whilea totalof127deathswerereported.Thenationwide14-daydelay- adjustedcasefatalityratewas1.4%(95%confidenceinterval:1.2%, 1.6%) for the current study period. The second wave of the
*Corresponding authorat: School of TropicalMedicine and GlobalHealth, NagasakiUniversity,1-12-4Sakamoto,Nagasaki852-8523,Japan.
E-mailaddress:[email protected](C.F.S.Ng).
https://doi.org/10.1016/j.ijid.2020.10.027
1201-9712/©2020TheAuthor(s).PublishedbyElsevierLtdonbehalfofInternationalSocietyforInfectiousDiseases.ThisisanopenaccessarticleundertheCCBY-NC-ND license(http://creativecommons.org/licenses/by-nc-nd/4.0/).
InternationalJournalofInfectiousDiseases101(2020)409–411
ContentslistsavailableatScienceDirect
International Journal of Infectious Diseases
j o u r n a l h o m ep a g e : w w w . e l s e v i e r . c o m / l o c a te / i j i d
epidemicbegan onFebruary27 andgrewatarate of18%(95%
confidenceinterval:15%,21%)perday,withadoublingtimeof3.8 (3.3,4.5)daysinthefirstmonth(Figure1).Iftherehadbeenno intervention,dailycaseswouldhaveexceeded400afterMarch26 and escalatedthereafter.Theepidemicdecayedslowlyata rate of 4%( 5%, 3%)afterMarch26,withahalvingtimeof18.1(14.1, 25.2)days.Transmissibility,representedbyRt,peakedat3.1(95%
credible interval: 2.7, 3.5) on March 15 and declined sharply afterwards,reaching1approximately3weeksafterthenational MCO(2weeksaftertheenhancedversionofthemeasure),and stayingbelow1fortherestofApril(Figure2).
Discussion
Our results suggest thattheCOVID-19 epidemicin Malaysia appearstobeundercontrol.Analysesshowedthatapproximately 3 weeks after the MCO, disease transmissibility had reduced substantiallyandremainedlowfortheremainingperiod,except fortwoupswingsinlateMayandearlyJuneduetotransmissions among foreigners in detention centers (Figure 2) (Ministry of HealthMalaysia(MOH,2020).Declineintransmissibilitystarteda fewdaysbeforetheofficialMCOmeasure,likelybecauseofmore public awarenessand reduced social mixing because of earlier reportsofincreasesinconfirmedcases.
Amixtureofinterventionswasimplementedtocurbspread.In theearlystagesofthesecondwave,authoritiesrespondedwith
MCO, a strict nationwideorder to limit movement and border travel, in addition to ongoing contact tracing and proactive surveillance among individuals with influenza-like illness and severe acute respiratory infection. Community-targeted mass testing was also implemented selectively to contain epidemic hotspots. The exit strategy was executed in a few stages. The nationalMCOwas replacedbyCMCO and eventuallybyRMCO, whilenumerousnewsocialdistancingmeasureswereintroduced tosuppressspreadandpreventresurgence(Petersenetal.,2020).
Forexample,restrictiononthenumberofworshiperstothesizeof thebuildings,staggeredreopeningofschoolsprioritizingstudents whowillbetakingschoolleavingexaminations,alimitationof250 peopleinpublicevents, andaccess todigitaltechnologytoaid contact tracing,interstate traveland self-evaluation– which is usefulforthoseundersurveillanceorquarantine(Petersenetal., 2020).Thesestrategiesareconsistentwiththesuggestionsofsome earlyreportsthatnotedcombiningmultiplemeasuresmightoffer effectiveoptionstominimizetheriskoffurtherlockdowns(Chen etal.,2020;Coulbourn,2020;Cowlingetal.,2020;Giordanoetal., 2020;Premetal.,2020).
Our observations suggest that intermittent triggering of adaptive measures coupled with population-wide distancing policiesandproactivesurveillancehaveprovidedeffectivecontrol againsttheepidemicinthecountry.Untilviablepharmaceutical options become available, the continuous evaluation of non- pharmaceutical strategies and the support for those Figure1.DailyCOVID-19casesfromJanuary25toAugust31,2020,shownasverticalbars.Verticaldashedlinesindicatethestartofcontrolmeasures.Solidcurvedlines representthepredictednumberofdailycasesforthesecondwavebasedontwoexponentialmodels:oneforthegrowthphasefromFebruary27toMarch26(asterisk),and anotherforthedecayphasefromMarch27toMay3,adaybeforetheCMCO.Dottedlinesrepresentthecorresponding95%confidenceinterval.
Figure2. Instantaneousreproductionnumberestimatedoverweeklyslidingwindowsforthesecondwave,shownasasolidline.Theshadedareaalongthesolidline representsthecorresponding95%credibleinterval.BackgroundshadingdenotesthedifferentperiodsunderMovementControlOrder(MCO),ConditionalMovementControl Order(CMCO)andRecoveryMovementControlOrder(RMCO).
C.F.S.Ng,X.T.Seposo,M.L.Moietal. InternationalJournalofInfectiousDiseases101(2020)409–411
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disproportionately affected will be important (Armitage and Nellums,2020;Chungetal.,2020;Dornetal.,2020).
Authors’contribution
CFSN and XS conceived the study with input from MS,MLM, LM and MABAT.CFSNextractedthedatawhichwerevalidatedbyMABAT.
CFSN led the analysis with inputs from XS and MS.All authors contributedtotheinterpretationandwritingofthefinaldraft.
Fundingsource
ThisworkwassupportedbyJapanAgencyforMedicalResearch andDevelopment(AMED)[GrantNumber20wm0125006]underthe JapanInitiativeforGlobalResearchNetworkonInfectiousDiseases(J- GRID)program.Thefunderhadnoroleinthestudydesign,collection ofdata,preparationofthemanuscript,ordecisiontopublish.
Ethicalapproval None.
Conflictofinterest Nonedeclared.
AppendixA.Supplementarydata
Supplementarydataassociatedwiththisarticlecanbefound,in theonlineversion,athttps://doi.org/10.1016/j.ijid.2020.10.027.
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