Analysis: The masks are off but a disaster is not inevitable

Over a week ago, World Health Organisation director-general Tedros Adhanom Ghebreyesus said at a briefing that the end of the COVID-19 pandemic was nigh.

Then the kicker - US President Joe Biden said in an interview that "the pandemic is over". Most epidemiologists and public health experts disagreed. However, a few agreed, stressing the end of a pandemic meant the end of the emergency state of the disease.

Here in Malaysia, where we seem to be treating the pandemic as if it is over, many health professionals subscribe to this belief. After Singapore lifted mask mandates, medical professionals including the Malaysian Medical Association (MMA) recommended we do the same, lifting the requirement in most places except on public transport and in healthcare and elderly care centres and other high-risk settings.

"We have much better control over COVID-19 now compared to the earlier stages and because of this, I think people feel more confident moving on," MMA president Dr Muruga Raj Rajathurai said via WhatsApp.

The reason for such confidence is the low rate of deaths, globally and domestically. Globally, the week of Sept 12 to 18 recorded the lowest number of deaths since March 2020 with over 10,000, a decrease of 14.65 percent from the previous week.

The world has changed since COVID-19 made its debut towards the end of 2019. Since then, many countries, including Malaysia, have vaccinated almost all its population and have access to boosters and new antivirals to prevent severe cases and deaths.

Despite the lower fatality rate, most public health experts remain concerned over a future with no masks. It will not only leave the onus of protection on the vulnerable, but will also allow the virus to spread unchecked, cause long-term complications and give rise to more dangerous mutations.

In other words, are we headed to a disaster?

COVID-19 FUTURE

Most health experts do not actually think Malaysia is headed for disaster, at least not of the acute, emergency kind. There are enough tools to help prevent severe cases and deaths. There are also surveillance systems in place so a full-blown crisis like before is unlikely. But while we have reduced the chances that the emergency will return, experts say we have not done enough to prevent slow-moving problems in the future.

One issue with lifting the mask mandate is that the public may take it to mean that the coronavirus is no longer a threat.

"The public feels like, okay, we had these two years of disaster and then I've been vaccinated and I've been reinfected a couple of times ... and they feel like, hey, it's not that bad. So it gives a false pretense that here we have another seasonal flu type of disease. That's the problem we are facing now," said Dr Vinod Balasubramaniam, a molecular virologist at Monash University-Malaysia.

On top of it, testing has also fallen by the wayside. Pharmacists Bernama talked to said sales of the COVID-19 self-test kit have gone down. According to the Ministry of Health's COVIDNOW website, the test positivity rate in Malaysia is seven percent. Public health experts say a positivity rate of under five percent is a sign that an outbreak is under control.

Unchecked spread of COVID-19 means more people will be infected, some again and again, thus increasing their risk of long-term and potentially severe conditions.

Epidemiologist Datuk Dr Awang Bulgiba Awang Mahmud said preventing infection should still be a primary concern as COVID-19 has long-term effects that many people may not be aware of.

"For example, there's worry that COVID-19 increases the risk of Type 2 diabetes and the risk of heart diseases as well as neurological and psychiatric disorders," he said.

Should that be true, such findings would increase the burden of these diseases on Malaysia's healthcare system. As it is, about one in five adults in Malaysia has diabetes. The top three causes of death in Malaysia are ischaemic heart disease, pneumonia and cerebrovascular disease, according to the Department of Statistics Malaysia.

Another concern is long COVID. There are news reports of COVID-19 patients exhibiting or developing symptoms, including brain fog, depression and cough, long after they have recovered from the illness. Some patients have also reported becoming disabled and no longer able to work.

Dr Vinod is especially worried about how COVID-19 would affect children in the long term as most studies have dealt with adults.

"What happens if a child gets reinfected multiple times? That's a worry you should think of, you know. But in the long (term) we know that even with a single infection, with a single reinfection that long COVID is possible. What happens if a child gets multiple infections with various strains? This is why masks are still relevant, masks are extremely important," he said.

Dr Awang Bulgiba, who published a research paper on it, told Bernama via email scientists still do not know enough about the condition.

"(W)e are uncertain about the true root causes of long COVID and whether repeated COVID-19 infections will worsen long COVID in time. With the above in mind, there is a worry that we are making assumptions that the SARS-CoV-2 has permanently become weaker and therefore the mask mandate is no longer necessary," he said.

He added there is no evidence to support the popular belief that the virus would ultimately mutate into something mild.

Although BA.5 is the dominant strain of Omicron COVID-19 in the world right now, its sub-variant BF.7 has become prevalent in Belgium, Denmark, Germany and France. So far, there is no sign the sub-variant is more deadly than its parent.

MESSAGING

All health experts stressed the importance of wearing a mask when needed, even if it is no longer required.

MMA's Dr Muruga Raj said lifting the mask mandate came with a caveat - the public should be continually educated that wearing a mask was still important, especially in some circumstances.

"Yes, of course, many will think that if wearing a face mask is not mandatory then it is not serious. Continuous public education and reminders about when to wear a mask are needed," he said.

Dr Awang Bulgiba concurred, adding that the inability to communicate health information well to the public has caused them to misunderstand the risks of the disease. He stressed the importance of data and warned against flip-flopping on the messaging.

"The health authorities need to be very careful in the way they package the message. To rescind this advice and exhort the public to adhere to stricter non-pharmaceutical interventions if a new and more virulent variant emerges will not be easy and can potentially lead to confusion," he said.

An example of health messaging that backfired pertains to vaccines. In late 2020, health authorities and pharmaceutical companies were so focused on getting the vaccine out and trying to convince people to get vaccinated - while also battling skepticism and misinformation - that they may have oversold the vaccine's abilities to prevent infection.

So while 85 percent of the Malaysian population has received two doses of the COVID-19 vaccine, less than half have gotten a booster shot and only 1.5 percent have gotten the two boosters.

Health experts told Bernama there is low awareness and urgency among the public, as well as the healthcare community, to get one booster shot, let alone two.

"(Some of my) friends, colleagues - they say the vaccines are good enough, plus the natural infection. Maybe not many people go for the second booster. This is (happening) even among people in healthcare," said Datuk Dr Zainal Ariffin Omar, advisor to the Public Health Organisation Malaysia.

The issue is that there is some confusion about how vaccines are supposed to work. Many thought the vaccines were supposed to prevent infection, and if the COVID-19 virus had remained the same, the vaccines would probably have.

But the coronavirus mutated to become more and more infectious and deadly, such as the Delta variant. The current variant is Omicron, which has a huge number of mutations including some genetic material from a coronavirus that causes the common cold. The mutations led Omicron and its sub-variants to cause a more infectious but less severe form of COVID-19. They also enabled the virus to break through the vaccine's preventative wall but not its protective effects.

The US Centers for Disease Control found that the two boosters prevent 92 percent of deaths while one booster or two doses of vaccine were 82 percent effective in preventing death. Health experts said the vaccines also likely reduce the risk of developing long COVID and may even alleviate symptoms of long COVID in some cases.

Dr Zainal said the ship has likely sailed on convincing everyone to get boosted. Instead, he said the government should step up and make boosters available on demand to anyone who wants it.

"Some people want a second booster and go to the clinic but the staff tell them it is not yet policy to give them the booster. Yes, it's optional but you should give it to anyone who walks in," he said.