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The Malaysian Response to COVID-19: Building Preparedness for ‘Surge Capacity’, Testing Efficiency, and Containment

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The Malaysian Response to COVID-19:

Building Preparedness for ‘Surge Capacity’, Testing Efficiency, and Containment

A report by Fifa Rahman* in collaboration with www.dndi.org

 

Executive Summary

At the time of publication of this report, there have been over 7.6 million COVID-19 cases and over 425,000 deaths from COVID-19 globally. In April and May 2020, these deaths were initially dominated by five countries in the West, notably the United States, Italy, the United Kingdom, Spain, and France. At time of publication, Brazil has entered the top five and displaced the United Kingdom. This reality has challenged the idea that expertise, and indeed the robustness of health systems, ‘is concentrated in, or at least (is) best channeled by, legacy powers and historically rich states.’[1] Instead – countries in the East have shown innovative and speedy pandemic responses that have kept infections and deaths relatively low compared to the West.

One of these countries is Malaysia. An upper middle-income country with a population of 32 million people, it has in recent years made a number of public health achievements – the issuance of a government use license for access to generic Hepatitis C drugs,[2] ranking highly on Bloomberg’s Healthcare Efficiency Index,[3] and eliminating mother-to-child transmission of HIV and syphilis.[4]

This situation brief details Malaysia’s response in the first phase of infections, beginning from December 2019 through to April 2020, and was informed by in-depth interviews with a number of key stakeholders in the Malaysian response, notably Datuk Dr Noor Hisham Abdullah (hereinafter Dr Noor Hisham), Director-General of the Ministry of Health and member of the Board of Directors for DNDi; Dr Hishamshah Ibrahim, Deputy Director-General for Research and Technical Support at the Ministry of Health; Dr Suresh Kumar, infectious diseases physician at Sungai Buloh Hospital, one of 40 hospitals nationwide designated as a COVID-19 hospital; Dr Ravindran Thayalan, Head of Virology Unit, Institute for Medical Research; Dr Melor Mansor, a COVID-19 frontliner and consultant anesthesiologist at Kuala Lumpur General Hospital; Prof Datuk Dr Rahman Jamal, head of taskforce for MOSTI-MOHE COVID-19 testing laboratories; Jean-Michel Piedagnel, Director of DNDi South East Asia; and Mr Lambert, a 62-year old patient who survived COVID-19.

These narratives as exemplified in these following pages illustrate the value of coordination and early preparations in delivering a robust public health response, that diagnostics capacity and efficiency was imperative, and, to quote Dr Mike Ryan, Executive Director of the WHO Health Emergencies Programme, that “Speed trumps perfection… the greatest error is not to move.”[5] Echoing this, Dr Feroza Sulaiman, Special Officer to the Director General of Health Malaysia, “We acted quickly, but we also used basic public health tools – social distancing, advocating the wearing of face masks in public spaces, contact tracing, frequent hand-washing. These were early key interventions while awaiting further evidence-based recommendations.”

 

In summary, this situation brief finds:

  1. Malaysia’s preparedness and planning began in December 2019, when they first heard from Chinese authorities that there were cases of acute respiratory illness;
  2. Previous experience with MERS and the 2002-2003 severe acute respiratory syndrome (SARS) epidemic, including experienced contact tracing teams, was key in enabling a speedy response;
  3. Malaysia drastically upgraded health facilities and diagnostics capacity in February 2020, including an 86% increment in diagnostics laboratory capacity, 89% increment in critical care bed capacity, and an 49% increase in the number of available ventilators (from 526 to 1034 units);
  4. Malaysia hospitalised all individuals diagnosed as COVID-19 positive, whether symptomatic and asymptomatic;
  5. Learning from other countries, including China was essential in identifying do’s and don’t’s in the COVID-19 response, including in terms of treatment;
  6. While evidence on treatments was still murky, Malaysian physicians prioritised monitoring for negative side-effects of treatments and adjusted medication regimens

 

The Beginning of the COVID19 Outbreak in Malaysia

At the end of December 2019, Chinese public health authorities reported several cases of acute respiratory syndrome in Wuhan, China. When the Malaysian authorities heard that an ‘unknown virus’ had precipitated these cases, the Malaysian health authorities were on high alert and believed that these could culminate into a major health concern in the region.[6] Planning and preparedness began then, including coordination with public health teams, plans for renovation of hospitals for surge capacity, and plans for procurement of reagents.

But it would be a month or so before the first cases were detected in Malaysia. On 23 January 2020, eight Chinese nationals entered Malaysia via Johor Bahru on Malaysia’s Southern border with Singapore. These travellers had been close contacts with a COVID-19 index case detected in Singapore, and all eight were tested for COVID-19. On 25 January 2020, a public announcement was made that three of these individuals had tested positive for COVID-19. In total, Malaysia recorded 22 cases in January 2020, all of which occurred via imported cases.[7] On 26 January 2020, the Ministry of Health (hereinafter MOH) first advised Malaysians to avoid crowded places when travelling to China.

Cases in February 2020 were largely imported cases as well. According to Dr Noor Hisham,

“A serious concern for a more massive COVID-19 outbreak in Malaysia was when we received notification on 9 March 2020 from our counterpart in Brunei Darussalam about a positive COVID-19 case detected in their country. The case was epidemiologically linked to an annual mass religious assembly at Seri Petaling Mosque, Kuala Lumpur held between 27 February to 1 March 2020 involving more than 14,500 local and 1,500 international attendees.”[8]

By mid-March, more than half of Malaysia’s 673 confirmed cases were linked to this mass religious event.[9] By 10 March 2020, the newly-appointed Malaysian Prime Minister advised the public to practice social distancing, and on 11 March 2020, the WHO declared the COVID-19 outbreak as a pandemic. On 12 March 2020, the government made the decision to designate Sungai Buloh Hospital, a public hospital approximately 25kms northwest of Kuala Lumpur, as the country’s main COVID-19 hospital.[10]

Following the substantial number of COVID-19 cases reported domestically following the religious gathering in Sri Petaling, the Government of Malaysia made the decision to implement lockdown via a Movement Control Order (MCO) nationwide, beginning from 18 March 2020.

 

Planning and Preparedness for ‘Surge Capacity’

Planning and preparedness activities began relatively early in Malaysia, with initial planning starting in December 2019, diagnostic reagents procurement in January 2020, and a number of renovations to hospital facilities done in February 2020. In the West, the EU had made an announcement that they would assist countries in the EU in COVID-19 joint procurement schemes on 31 January 2020, with countries in the EU being at various stages of procurement for both protective and medical gear in April 2020.[11]

According to Dr Suresh Kumar, an infectious diseases clinician at Sungai Buloh Hospital:

“In February we started emptying the hospitals. Surgeons had to do surgeries elsewhere so we could clear ICU beds of post-op patients. Other hospitals took the brunt so that we could focus on COVID-19. We started building capacity when we heard how Wuhan was overwhelmed. We knew that a lot of the mortality in Wuhan was because of the surge (in cases) and the fact that their hospitals couldn’t cope. So we started building surge capacity. I’ll give you an example of this – Sungai Buloh is actually a 900-bedded hospital. We made renovations to make sure it could accommodate over 2000 bedded patients. There was an old hospital next door that we immediately renovated and brought in beds to get it ready. We also learned from China that their ICUs were totally overwhelmed – so we then reviewed our own ICUs to see what else we could convert into ICUs. We saw that the daycare centre could become ICU beds, that the operating theatre could include ICU beds. We seem to have come out of this without our hospitals getting overwhelmed.”

In the meantime, efforts were taken to optimise diagnostics capacity within both public and private laboratories. Laboratories within the Institute for Medical Research (IMR), the biomedical research arm of the Ministry of Health, ordinarily carries out over 300,000 specialised diagnostic tests per year as well as training for laboratories nationwide, and began preparations in January. Dr Ravindran Thayalan, head of the virology unit at the IMR, elaborates:

“We already had the capacity to diagnose and detect SARS, the previous strain, but with this we didn’t initially know what we were dealing with. 11th January 2020 was when Chinese scientists shared the full genomic sequence of this coronavirus on platforms like GISAID. So we had access to that and based on that we managed to optimise our services by designing and developing our own primers and probes specific for COVID-19. The reagents arrived on 21st of January and we optimised our real time PCR by that day itself. In the meantime, what we needed to do was provide training to other government facilities and public health laboratories. So on the 13th of January as a first step we delivered training for 12 government hospital labs.”

Previous experience with infectious diseases was evident and in fact was attributed as one of the key reasons for preparedness and relative success in the COVID-19 response, which is consistent with accounts in medical journals and in international press.[12] In the words of Dr Noor Hisham:

“(Malaysia) acted promptly in responding to the COVID-19 pandemic. Partly this is due to our experience in containing past infections such as SARS (Severe Acute Respiratory Syndrome), Nipah virus encephalitis and MERS (Middle East Respiratory Syndrome). These outbreaks had made Malaysia more prepared to deal with such situations, including having more thermal scanners which have been placed at all entry points into the country, as well as its actions in isolating COVID-19 cases and placement of suspected cases under quarantine.”

Overall, Malaysia’s COVID-19 preparedness and planning activities led to a remarkable 86% increment in diagnostic laboratories. A joint effort occurred between the Ministry of Higher Education (MOHE – in charge of university hospitals) and the Ministry of Science, Technology, and Innovation (MOSTI) to mobilise 10 university labs as well as an additional lab at the Malaysian Genome Institute under MOSTI.[13] This meant that diagnostics capacity for COVID-19 increased from an initial 6 laboratories to 43 laboratories at time of writing, including those in public hospitals, public health laboratories, IMR, university laboratories, laboratories within the Malaysian Armed Forces, the Malaysian Genome Institute, and private laboratories.[14] According to Dr Noor Hisham:

“The ability to keep deaths low is also partly attributed to the early planning and preparedness of our public health and hospital facilities and services. From December 2019 to April 2020, in addition to increasing capacity and the number of diagnostics laboratories, we increased the number of hospitals treating COVID-19 patients from 26 hospitals to 40 hospitals, including 7 which function as full COVID-19 hospitals; we increased the number of screening hospitals from 56 to 120 which is a 53% increment; and we also increased ventilator numbers from 526 units to 1034 units, which is a 49% increment.”

The mobilisation of ventilators in particular was marked not just by procurement efforts, but also via nationwide mobilisation of ventilators from the private sector. Dr Suresh Kumar, infectious diseases clinician at the main COVID-19 designated hospital in Malaysia, Sungai Buloh Hospital describes: “Everyone was clamouring for the same ventilators from manufacturers in China. When they said they couldn’t give them to us, that’s when Plan B started to get private hospitals to just lend their ventilators over to us.”[15]

 

Malaysia’s Response in Action

In contrast to countries in the West, Malaysia hospitalised all individuals diagnosed as COVID-19 positive,[16] including asymptomatic patients and individuals who have reported close contacts with confirmed COVID-19 cases, or with travel history to high burden areas. Dr Noor Hisham elaborated further, including on those individuals who had some form of Severe Acute Respiratory Illness (SARI):

DG

“To enhance the quality of care and to reduce morbidity and mortality, all patients including asymptomatic (patients) are admitted to hospital. Hence all patients with COVID-19 will be able to be monitored and be given appropriate treatment. Besides that, Patients Under Investigation (PUI) with close contact or travel history and SARI are also admitted as some of them could be potentially COVID-19 positive. The objective of admitting these patients is to rule out COVID-19 infection. A standard clerking format in used to ensure key clinical data are recorded ensuring nothing is missed. Close monitoring on a daily basis allows treatment with hydroxychloroquine to be initiated early when indicated.” [1]

Hydroxychloroquine has been subject to recent controversy, with reports of deaths due to reported arrhythmia and cardiac arrest among patients prescribed the medication.[17] A clinical trial in Brazil, for example, found higher mortality in patients who received high doses (i.e. 600mg twice daily for 10 days or total dose 12g) of hydroxychloroquine versus lower doses.[18] A recent Lancet study [19] also associated hydroxychloroquine with higher in-hospital mortality. However, this study has attracted some scrutiny from statisticians and medical scientists, especially because hydroxychloroquine has been ‘in use in hospital settings for decades and had not shown such major negative effects in studies up until this point’.[20] Studies continue to emerge at time of writing indicating no statistically significant benefit.[21] Based on testimonials recorded for this paper, Malaysia relied on Chinese experience that the lower doses were efficacious, while monitoring closely for heart issues, while at the same time acknowledging that there was a need for high quality evidence.

Dr Suresh Kumar, infectious diseases clinician at the main COVID-19 designated hospital in Malaysia, Sungai Buloh Hospital, elaborated:

“We needed to work on what was available at that particular juncture. At that particular juncture – albeit there not being high quality evidence – we learned from Chinese experience that hydroxychloroquine works, we prescribed hydroxychloroquine early for all symptomatic patients. And on the issues aired on various forums – we didn’t use the high dose hydroxychloroquine that Brazil said is harmful – we used the lower dose one that the Chinese recommended. We did use it not with azithromycin because we were worried about the cardiac problems. We monitored with ECG and we didn’t find anything major. It became our anchor when many patients became sick. Of course, we also tried various combinations of HIV drugs, like Kaletra, and also tried using interferon, which is an antiviral.”

Crucially, Dr Suresh’s testimonials illustrated the challenges of working in an environment of imperfect information and the need for ingenuity and persistent learning as new evidence emerged. For example, he detailed how he and other clinicians learned early on that inflammation was a major factor in deaths, and so treatment was modified to include anti-inflammatories:

“If we had had the disease a lot later down the track we could’ve learned a lot more from the Italians and the Chinese and we learned early that some of these patients were deteriorating not because of the virus (directly) but because of the inflammation (caused by the virus). So quite early on we learned to use anti-inflammatory agents in selected cases that were undergoing deteriorating. We were able to prevent the ICU admissions by doing that.”

Learning was also enabled via WebEx meetings held twice a week among COVID-19 frontliners nationwide. These mortality reviews were described by Dr Melor Mansor, COVID-19 frontliner and consultant anesthesiologist at Kuala Lumpur General Hospital:

“We went through each of the deaths of COVID patients, looking through to see how best we could improve upon clinical management and then make recommendations that can be shared throughout the country.”[22]

Dr Suresh’s testimonials also indicated that data was being collected and would be contributed to the global pool of evidence: “The jury is still out in terms of whether we made a difference with antivirals. We are trying to collect data and see whether we made a difference with hydroxychloroquine, but also in terms of the use of anti-inflammatory agents to prevent ICU admissions.”[23]

Malaysia’s relative success wasn’t just limited to what occurred in hospitals upon admission. Mass testing in specific identified high-burden zones, as well as diagnostics efficiency, was crucial. Dr Ravindran Thayalan, head of the virology unit of the IMR, described how testing outreach occurred:

“The PKD (Pejabat Kesihatan Daerah – District Health Office) public health team would go and take samples from, for example, a block of apartments in a particular area, with an estimated head count of 2000 people. These samples will then be sent to a national lab or the Institute for Medical Research (IMR). They will then let us know how many samples are coming, and a designated target as to when those tests will be completed – i.e. 12,000 tests have to be completed in 2-3 days.”

Dr Ravindran also described the capacity of testing per day nationwide, and the recent addition of another automated PCR machine to increase capacity:

“According to today’s (30 April 2020) count, we can go up to 14,000 tests at capacity. This includes all labs in Malaysia, including private labs, university labs, and government labs. We’ll soon add an additional machine to the IMR called the Beijing Genomics Institute (BGI) Fire Eye which can do 5,000 tests a day, bringing our target capacity up to 16,000 to 20,000 tests a day.”[24]

Contact tracing as a method to control infections was evident throughout Malaysia’s COVID-19 response. In an April 26th press briefing, for example, Malaysia’s Director-General of Health Dr Noor Hisham Abdullah spoke about Malaysia’s ‘active case detection’, in particular about a trader in a wholesale market located in Selayang who had tested positive, MOH’s decision to shut down the specific market, and test all 60 traders at the market, who by virtue of being regular traders there were deemed as ‘having close contact’ to the trader detected as COVID-19 positive.[25] This was just one of daily briefings by the Director-General of Health to keep Malaysians aware of new infection clusters, guidelines, and updates in the Malaysian COVID-19 response. On effective communication in a pandemic, Dr Noor Hisham stated:

“I strongly view that addressing COVID-19 is an all-of-government, all-of-society responsibility. Effective resilience and response will take a joint effort to a shared threat including coordinated and integrated response across all sectors, with regular and timely communication across various sectors involved. The community’s engagement is critical. It is crucial for the governments to invest resources, time and effort into risk communication and community engagement that puts listening on an equal footing with speaking. Communicating effectively with the public and engaging with communities, local partners and other stakeholders to help prepare and protect individuals, families and the public’s health during early response to COVID-19, is essential to our collective success in responding to this pandemic.”[26]

Dr Suresh Kumar described how contact tracing expertise and efficiency was something that had been built up over a longer period of time and through expertise with other disease outbreaks:

“We have regular dengue, tuberculosis, all these diseases which require contact tracing. So we have a big, very good and very experienced public health team that has been doing contact tracing regularly. In countries where these other infections were very low, they perhaps weren’t used to contact tracing at the scale we are (used to).”

In other words, Malaysia’s response was powered by early preparedness, robust contact tracing teams, diagnostics capacity and efficiency, treatment teams that worked on the available knowledge and resources that they had, and strict lockdown measures. In these circumstances, it truly seemed that the words of Dr Mike Ryan – ‘speed trumps perfection’ – illustrates Malaysia’s experience well. Further illustration is provided through this patient and frontliner testimony:

 

Figure 1: Patient Experiences on Malaysia’s COVID-19 Frontline

We interviewed one Mr Lambert,[1] a 62-year old male who presented at a government healthcare clinic with symptoms, but also with reported contact with someone who had tested positive for COVID-19. He had initially presented at the clinic on Friday the 20th of March 2020, but as he had not reported previous contact with a diagnosed case, he was not initially given a test. “It was only on Saturday (21st March) afternoon that I heard on my neighbourhood chat group that one of our neighbours, someone I’d been sitting with and chatting with at our local mosque, had been diagnosed as positive for COVID19,” he described. “But due to the clinic being closed on Sunday, I only went to the clinic again on Monday the 23rd and informed them that I’d been in contact with a COVID-19 patient. The clinic did blood pressure and oxygen intake tests, and after a discussion they decided to send me to the hospital as they considered me to be a ‘patient under investigation’ (PUI).”[1]

It was when he arrived at Sungai Buloh that he was given a nasopharyngeal swab test and diagnosed as positive for COVID-19 and admitted into an isolation room and given an x-ray. He was informed that the virus had attacked his lungs.

“I was initially in isolation and was given an x-ray. The doctor informed me that the virus had attacked my lungs. I was given three types of medication – I think one of them was mentioned (in the news) as maybe not very good, but I think it really helped me.”

Mr Lambert’s testimonial also described how patients who were hospitalised would be placed in quarantine once their conditions had been deemed stabilised, and that they received nasopharyngeal swab tests every two days:

“After nine days in the hospital, my condition was better than before. I basically had no more coughing and no more shortness of breath, so they transferred me to a place nearby, outside the hospital. This is where they quarantined people who were already stable. It was a hostel that formerly was some kind of training institute for health workers. They put me there with other COVID19 patients who were still testing positive, but who were relatively healthy and who didn’t need much medical attention. There they did the swab tests every two days. On the sixth test, on the 15th of April 2020, I finally got a negative result and was allowed to return home.”

Testimonials also indicated the harrowing circumstances under which frontliners worked. In a particularly difficult COVID-19 case at the Kuala Lumpur General Hospital in the centre of the city, Dr Melor Mansor described needing to do a tracheostomy for a COVID-19 patient with underlying conditions, notably cancer of the larynx, and who had difficulty breathing. He described how patients could be facing anxiety just from being surrounded by people decked in full PPE, as well as the additional stress of having underlying conditions, and illustrated the role of frontliners in assuring patients. “I told him basically to be calm, that we could handle his situation well.”[1]

 

The Way Forward in Research and Development

Malaysia is participating in a number of R&D initiatives in COVID-19, including a clinical trial on the treatment of tocilizumab for severe COVID-19 cases,[27] through the WHO-led SOLIDARITY trial which includes remdesivir-based regimens, and through participating in the Clinical Research Coalition (CRC) https://covid19crc.org/ for COVID-19, which brings together an array of health experts, including public-sector research institutes, ministries of health, academia, not-for-profit research and development organisations, NGOs, international organisations, and funders which are all committed to finding COVID-19 solutions for resource-poor settings.[28]

Malaysia is also playing a leading role in insisting that clinical trials are conducted in geographically diverse regions, with ethnically diverse participants, and in resource-poor settings. On this point in particular, Dr Noor Hisham stated:

“While there are almost 600 COVID-19 clinical trials registered, very few trials are planned in resource-poor settings. Some countries do not get the opportunity to conduct these important studies. It is crucial to have a fast and efficient approval system. Hence, we have revisited our approval process to allow COVID-19 related trials to be conducted in an expedited manner. Speed is critical in this unprecedented situation.”

On ethnic diversity within clinical trials, Dr Noor Hisham stated:

“Due to its unique multi-ethnicity, Malaysia could claim a third of the world’s population genomics. In addition, its health system is comprehensive, encompassing primary, secondary and tertiary healthcare. This network helps us to treat and study the disease in an efficient manner. All these make up an additional value proposition which Malaysia can offer the world of science. This is another contributing factor why Malaysia is part of the CRC.”[29]

He added, “The scale of the challenge is clearly beyond the scope of any single organisation. The coalition will facilitate a coordinated approach, so that all data from all regions can be collected in a similar fashion, pooled and shared in real-time. This will help countries and the WHO to make rapid evidence-based decisions on policies and practice by sharing their technical expertise and clinical trial capability to accelerate COVID-19 research in these settings.”

Others interviewed for this brief report thought that domestic diagnostics and vaccine development could be improved. Dr Ravindran from IMR stressed the importance of investments to get ‘local players to develop reagents for us’ to prevent shortages in the future due to overreliance on other countries.[30] Dr Hishamshah Ibrahim, Deputy Director General of the Ministry of Health in charge of research and technical support, on the other hand, opined that there was a need to develop vaccine expertise for future pandemics:

“We are revisiting plans for a National Vaccine Centre. In my opinion, we should have established this years ago, but better late than never. It will of course take big capital expenditure and a long gestation period, but it’s worth investing in the long-term to develop domestic human vaccine expertise. In terms of COVID-19 it’s a little late for Malaysia to get involved in vaccine production, but in the short-term we think joint ventures would be a good idea. This would enable us to be involved in early phases of trials, technology transfer and priority access to effective vaccines. We have pockets of people domestically that have the requisite skills to be involved in vaccine research, we just need to bring them together, design a strategy, and mobilise the necessary resources.”

Prof Datuk Dr Rahman Jamal, Head of Taskforce for MOHE-MOSTI COVID-19 Testing Labs and Principal Research Fellow of the UKM Molecular Biology Institute (UMBI), highlighted research and development in other areas:

“There is also a lot of efforts on innovation coordinated by MOSTI, including special booths to do nasopharyngeal swabs (that would protect frontliners doing the swabbing), the use of robots in COVID-19 wards to deliver food to patients in isolation rooms as well as for sanitisation of rooms, as well discussions on collaboration with local and international researchers on clinical trials including for vaccines.”[31]

 

Analysis, Conclusions, and Recommendations

Malaysia has had relative success in responding to the COVID-19 pandemic, with deaths at time of writing standing at 120. This is despite a mass religious event setting off large numbers of infections in early March 2020. Based on testimonials in this report, this relative success is owing to early pandemic preparedness and planning, established contact tracing to enable a robust public health and primary healthcare response, a system of learning established through WebEx mortality reviews, various Whatsapp groups among infectious diseases clinicians in different countries,[32] and from genomic sequence information obtained off open science platforms such as GISAID, and strict lockdown measures.

The report also highlights the importance of a publicly funded health system to ensure testing and treatment for all. The experience of Mr Lambert highlights this; that he did not pay for any services during his stay in hospital and the quarantine centre from 21st March-15th April 2020. Diagnostics, treatment, and all meals (breakfast, lunch, tea, and dinner) were funded by the public health system. The importance of a public health system has started to be realised elsewhere, even in countries dominated by private insurance companies and capitalist health systems. In New York, for example, Governor Andrew Cuomo established a regional supply and procurement chain along with other North-eastern American states to procure USD$5b worth of equipment and supplies, and mobilised private and public hospitals to share patient capacity, equipment, ventilators, and staff. Cuomo stated: “That had never been done. We did this all basically on-the-fly. We put together a de facto public health system.”[33]

Malaysia’s relative success was also reflected in a number of other countries in the East, including Taiwan, South Korea, and Vietnam, dismantling belief that health security, expertise, and robust health systems were concentrated in the West. In fact, the 2019 Global Health Security Index ranks the United States and the United Kingdom first and second in terms of global health security. Given that these two countries are also the top two countries for COVID-19 deaths, it would perhaps be prudent to have a reassessment of criteria for this index.[34]

More importantly is the need for a separate analysis on the middle-income country response. Middle-income countries have relative resource scarcity to the Global North, but responded in ways that would prevent hospitals being overwhelmed. Vietnam, a lower-middle income country, for example, knew that it would not have diagnostics capacity to deal with a full-blown outbreak and began initiating responses in January 2020, with ‘urgent dispatches on outbreak prevention to relevant government agencies on January 16 and to hospitals and clinics nationwide on January 21’,[35] in addition to border control measures such as temperature screening, and extended contact tracing (where once a positive case was identified, contacts through five generations were traced).[36] Malaysia as an upper-middle income country had more diagnostics capacity, but largely had similar responses and with quicker responses relative to the Global North. Comparisons via an in-depth study could lend useful lessons for both high-income nations who have had high death rates and low-income nations, who have even more resource scarcity and need low-cost responses.

Like many countries, however, the response has had its imperfections. The response among migrants in particular have attracted close scrutiny. While in early May 2020 the Health DG emphasised that it was the MOH’s responsibility to test and treat all individuals in high risk groups regardless of immigration status,[37] a series of immigration raids and arrests [38] of undocumented migrants occurred in neighbourhoods with COVID-19 clusters and large migrant populations later that month, conducted by the Ministry of Home Affairs. While the Health DG has continued to stress non-discrimination in access to healthcare for migrants, including calling for immediate medical and decontamination procedures at detention centres [39] and the need for housing conditions for migrant populations to be examined,[40] the response in this regard requires policy coherence and human rights assessments, including on the right to health. Immigration raids and arrests are likely to drive migrants underground, impeding the COVID-19 response and presenting infection risks.

 

In summary, conclusions of this brief report are as follows:

  • A coordinated and comprehensive response in a pandemic requires a public health system.
  • Acting quickly in a pandemic is crucial – speed trumps perfection.
  • Malaysia has a gap in domestic production capacity for reagents, as well as a gap in vaccine R&D expertise that should be invested in.
  • Clinical trials must reflect ethnic and geographical diversity, and more trials should be conducted in resource-poor settings.
  • Criteria for global health security indices should be revised.
  • Effective communication is key in pandemic response.
  • Neglect of migrant human rights constitutes COVID-19 infection risks and highlights the urgent need for a cohesive response at all government levels to improve the welfare and living conditions of the documented migrant population.
  • Malaysia’s relative success is attributable to a combination of early preparedness and planning, experiences in previous pandemics, diagnostics, public health system, contact tracing, and a strict lockdown, but may also be attributable to socio-demographic factors such as having an overall younger population than countries in the West.

 

“This report is important and timely. It illustrates the value of middle-income country expertise in global pandemic response. While there is a clear need to invest in more expensive solutions such as new treatments and vaccines, pragmatism and speed in terms of instituting a basic health response is a major factor. Middle-income countries focused on basic available public health tools. This is a lesson we all need to remember.”

Jean-Michel Piedagnel

Director, Drugs for Neglected Diseases initiative

Southeast Asia Office

 


* PhD University of Leeds; Board Member for NGO Delegation, Unitaid Executive Board; interim NGO representative for diagnostics on the ACT-Accelerator for the COVID-19 Global Response

[1] Sarah Dalgish, ‘COVID-19 Gives the Lie to Global Health Expertise’ (2020) 395(10231) The Lancet P1189 [2] Catherine Saez, ‘Malaysia Grants Compulsory Licence for Generic Sofosbuvir Despite Gilead Licence’ IP-Watch (15 September 2017) <https://www.ip-watch.org/2017/09/15/malaysia-grants-compulsory-licence-generic-sofosbuvir-despite-gilead-licence/&gt; accessed 5 May 2020 [3] Lee J Miller and Wei Lu, ‘These Are the Economies with the Most (and Least) Efficient Health Care’ Bloomberg (19 September 2018) <https://www.bloomberg.com/news/articles/2018-09-19/u-s-near-bottom-of-health-index-hong-kong-and-singapore-at-top&gt; accessed 5 May 2020 [4] WHO, ‘Malaysia Eliminates Mother-To-Child Transmission of HIV and Syphilis’ (8 October 2018) <https://www.who.int/westernpacific/news/detail/08-10-2018-malaysia-eliminates-mother-to-child-transmission-of-hiv-and-syphilis&gt; accessed 5 May 2020 [5] Dr Michael Ryan, Executive Director, WHO Health Emergencies Programme, SkyNews (13 March 2020) accessed 5 May 2020 [6] Email interview with Datuk Dr Noor Hisham Abdullah (Datuk Noor Hisham), Director-General of Health, Malaysia (22 April 2020) [7] Naomie Salim, Weng Howe Chan, Shuhaimi Mansor and others, ‘COVID-19 Epidemic in Malaysia: Impact of Lockdown on Infection Dynamics’ (2020) MedRxiv <https://doi.org/10.1101/2020.04.08.20057463&gt; accessed 12 May 2020 [8] DG Hisham (n 6) [9] Yudith Ho and Faris Mokhtar, ‘How a 16,000-Strong Religious Gathering Led Malaysia to Lockdown’ Bloomberg (17 March 2020) <https://www.bloomberg.com/news/articles/2020-03-17/how-a-16-000-strong-religious-gathering-led-malaysia-to-lockdown> accessed 12 May 2020 [10] Cindi Loo, ‘Sungai Buloh Designated as Hospital to Handle Covid-19 Outbreak’ The Sun Daily (12 March 2020) <https://www.thesundaily.my/local/sungai-buloh-designated-as-hospital-to-handle-covid-19-outbreak-FA2121733&gt; accessed 13 May 2020 [11] Jillian Deutsch, ‘Commission: UK had ‘Ample’ Chances to Join EU Procurement Scheme on Coronavirus’ Politico (22 April 2020) <https://www.politico.eu/article/coronavirus-commission-uk-had-ample-chances-to-join-eu-procurement-scheme/> accessed 13 May 2020 [12] Sarah Dalgish, ‘COVID-19 Gives the Lie to Global Health Expertise’ (2020) 395(10231) The Lancet P1189; Emma Graham-Harrison, ‘Experience of Sars a Key Factor in Countries’ The Guardian (15 March 2020) <https://www.theguardian.com/world/2020/mar/15/experience-of-sars-key-factor-in-response-to-coronavirus> accessed 13 May 2020 [13] Interview with Prof Datuk Dr Rahman Jamal, Head of Taskforce for MOHE-MOSTI COVID-19 Testing Labs and Principal Research Fellow of the UKM Molecular Biology Institute (UMBI) (Via email communication, 25 April 2020) [14] Datuk Noor Hisham (n 6) [15] Interview with Dr Suresh Kumar, infectious diseases clinician, Sungai Buloh Hospital (Whatsapp call, 23 April 2020) [16] John Bunyan, ‘Health D-G: Unlike Other Countries, Malaysia Wards Covid-19 Patients Until Fully Recovered’ Malay Mail (15 April 2020) <https://www.malaymail.com/news/malaysia/2020/04/15/health-d-g-unlike-other-countries-malaysia-wards-covid-19-patients-until-fu/1857010&gt; accessed 4 May 2020 [17] Kelly Servick, ‘Antimalarials Widely Used Against COVID-19 Heighten Risk of Cardiac Arrest. How Can Doctors Minimize the Danger?’ Science (21 April 2020) <https://www.sciencemag.org/news/2020/04/antimalarials-widely-used-against-covid-19-heighten-risk-cardiac-arrest-how-can-doctors#> accessed 14 May 2020 [18] Mayla Gabriela Silva Borba, Fernando de Almeida Val, Vanderson Sousa Sampaio, and others, ‘Chloroquine Diphosphate in Two Different Dosages as Adjunctive Therapy of Hospitalized Patients with Severe Respiratory Syndrome in the Context of Coronavirus (SARS-CoV-2) Infection: Preliminary Safety Results of a Randomized, Double-Blinded, Phase IIb Clinical Trial (CloroCovid-19 Study)’ (2020) <https://doi.org/10.1101/2020.04.07.20056424> accessed 14 May 2020 [19] Mandeep R Mehra, Sapan S Desai, Frank Ruschitzka, and Amit N Patel, ‘Hydroxychloroquine or Chloroquine With or Without a Macrolide for Treatment of COVID-19: a Multinational Registry Analysis’ (2020) The Lancet https://doi.org/10.1016/S0140-6736(20)31180-6 [20] Catherine Offord, ‘Disputed Hydroxychloroquine Study Brings Scrutiny to Surgisphere’ The Scientist (30 May 2020) < https://www.the-scientist.com/news-opinion/disputed-hydroxychloroquine-study-brings-scrutiny-to-surgisphere-67595?fbclid=IwAR1gJ5LPwhue1I1CFPk-TjHOqFppl3q8gAN9k9BKJIisS3vUBYmiwZz0qEY> accessed 31 May 2020 [21] Kai Kupferschmidt, ‘Three Big Studies Dim Hopes that Hydroxychloroquine can Treat or Prevent COVID-19’ Science (9 June 2020) <https://www.sciencemag.org/news/2020/06/three-big-studies-dim-hopes-hydroxychloroquine-can-treat-or-prevent-covid-19> accessed 13 June 2020 [22] Interview with Dr Melor Mansor, COVID-19 frontliner and consultant anaesthesiologist, Kuala Lumpur General Hospital (Whatsapp call, 7 May 2020) [23] Dr Suresh Kumar (n 15) [24] Interview with Dr Ravindran Thayalan, Head of Virology Unit, Institute of Medical Research (IMR) Malaysia (Whatsapp call, 30 April 2020) [25] Melissa Goh accessed 4 May 2020 [26] Datuk Noor Hisham (n 6) [27] Rayyan Rafidi, ‘UM Leads Clinical Trials for Tocilizumab in COVID-19 Treatment’ New Straits Times (13 April 2020) <https://www.nst.com.my/education/2020/04/583940/um-leads-clinical-trials-tocilizumab-covid-19-treatment> accessed 14 May 2020 [28] Datuk Noor Hisham (n 6) [29] Datuk Noor Hisham (n 6) [30] Dr Ravindran Thayalan (n 24) [31] Prof Datuk Dr Rahman Jamal (n 13) [32] Dr Suresh Kumar (n 15) [33] New York State, ‘Video, Audio, Photos & Rush Transcript: Amid Ongoing COVID-19 Pandemic, Governor Cuomo Announces Joint Multi-State Agreement to Develop Regional Supply Chain’ (3 May 2020) <https://www.governor.ny.gov/news/video-audio-photos-rush-transcript-amid-ongoing-covid-19-pandemic-governor-cuomo-announces-18?fbclid=IwAR1IxYyxX2ES5t6ZLZ87gmjJoqtncajSg7R_V2q8wIE8j3FZoIo9N6aZOsQ> accessed 14 May 2020 [34] Dalgish (n 1); 2019 Global Health Security Index <https://www.ghsindex.org> accessed 14 May 2020 [35] Minh Vu and Bich T Tran, ‘The Secret to Vietnam’s COVID-19 Response Success’ The Diplomat (18 April 2020) <https://thediplomat.com/2020/04/the-secret-to-vietnams-covid-19-response-success/> accessed 28 May 2020 [36] Linh Dinh et al, ‘Vietnam’s Response to COVID-19: Prompt and Proactive Actions’ (2020) Journal of Travel Medicine doi: 10.1093/jtm/taaa047 [37] Adam Aziz, ‘Health DG: MOH Role is to Eradicate COVID-19, Even Among Undocumented Immigrants’ The Edge Markets (1 May 2020) <https://www.theedgemarkets.com/article/health-dg-moh-role-eradicate-covid19-even-among-undocumented-immigrants> accessed 28 May 2020 [38] Emily Fishbein, ‘Fear and Uncertainty for Refugees in Malaysia as Xenophobia Escalates’ The New Humanitarian (25 May 2020) <https://www.thenewhumanitarian.org/news/2020/05/25/Malaysia-coronavirus-refugees-asylum-seekers-xenophobia> [39] Straits Times Singapore, ‘Malaysia’s Health Chief Warns against Discrimination of Migrant Workers Amid Coronavirus Outbreak at Detention Centres’ Straits Times (25 May 2020) <https://www.straitstimes.com/asia/se-asia/coronavirus-breaks-out-at-detention-centres-in-malaysia-health-ministry-warns-against> accessed 28 May 2020 [40] Datuk Noor Hisham Abdullah, in video tweeted (27 May 2020) accessed 28 May 2020