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Seeking truth from facts in Covid-19

Asia Analytica
Asia Analytica • 12 min read
Seeking truth from facts in Covid-19
It is possible that the world may never eradicate Covid-19, even with vaccines, not unlike the flu.
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Prior success does not mean much as far as combating the Covid-19 virus is concerned. Over the past week, Malaysia has seen a record-high number of new cases. The headlines are definitely worrying, but we are certainly not alone.

The rest of the world too is grappling with an upsurge in new cases, an ominous sign even before the northern hemisphere heads into colder winter months. This rising second-third wave is reported in countries that had previously managed to contain the spread via lockdowns and stringent restrictive movement measures as well as those that were largely spared the initial outbreak.

It is a stark reminder that we cannot afford to be complacent about the still-present risks. No one is immune. Not even the president of the US, who, together with his wife and several close aides, was confirmed positive for the virus. But it is also very important that we must not panic and overreact.

It is possible that the world may never eradicate Covid-19, even with vaccines, not unlike the flu. No vaccine will be 100% effective and the virus may continue to mutate and persist. Nevertheless, continued progress in medical science will surely make it less fatal, like it did with the human immunodeficiency virus (HIV) that causes AIDS.

The fact of the matter is, Covid-19 may turn out to be yet another disease that we will just have to learn to live with. It is the new normal — and as clichéd as they sound, these words are not to be taken lightly. And if that is the case, all decisions made in regard to the viral outbreak need to consider real world practicalities as opposed to being purely ideological.

We may have to revert to some of the previous restrictions such as 50% seating capacity for eateries and lowering the number limits for gatherings in mosques, churches, weddings, funerals and so on. Enforcement must be strengthened to ensure strict compliance with the standard operating procedures (SOPs) — for instance, mandatory wearing of masks and physical distancing in public places, temperature screening and check-in at malls. There may even be a need to implement enhanced targeted and localised movement controls.

But few countries — if any — will revert to the stringent nationwide lockdowns such as those imposed at the outset of the pandemic. There are very good reasons this must be the case.

The intent of the initial stringent lockdowns was to buy time, to allow countries and healthcare systems to be better prepared. We did that. But such lockdowns are unsustainable. The cost is too high, and is it not just the economic fallout.

Often lost among the headlines is the collateral damage. This includes lives that are, or will be, lost because of the postponement of routine medical care — such as going for cancer screening, where early diagnosis is critical for chances of recovery — and help for treatable and preventable diseases such as dengue and malaria as well as elective surgeries.

Delaying the recovery of economies and jobs will lead to loss of livelihoods. The pandemic is hitting the poorest the hardest. Poverty has cascading consequences such as domestic abuse and malnutrition that could result in a long-term health impact, even starvation and lives lost when people can no longer afford to seek medical treatment. Education, the most important bridge to income equality, gets bumped down in the priority list.

There is another important statistic against widespread lockdown — the death toll. The fatality rate varies from country to country, depending on a host of factors such as the extent of testing and tracing, cultural norms, demographics and quality of healthcare services.

Around the world, however, the number of daily deaths relative to new cases has been on a steady decline from the peak in April and May (see chart). The fatality rate will change throughout the duration of the pandemic — though we believe it will continue to drop. Why?

Experience and knowledge. Our understanding of the virus is growing by the day, from how best to protect against it and prevent infection to more effective diagnosis and treatment for the sick. Hospitals are much better prepared to handle the crisis today, with increased capacity and adequate personal protection equipment for medical personnel.

It could be that the majority of those infected currently are younger and therefore less susceptible. It could also be that the virus has mutated into a more infectious but less deadly strain.

Whatever the reason, the number of deaths resulting from current cases has fallen sharply from where it was at the beginning of the pandemic.

So, while everyone must still observe all the recommended precautions and act responsibly, we must also look at all the facts in their entirety and resist overplaying and inflaming fear that will benefit few and result in even greater loss of livelihoods and lives in the long run.

This may be hard to hear but, in life, every decision involves some trade-off. As we have pointed out previously, our consent to the government’s co-opting of mobile phone data for contact tracing trades individual privacy for public health safety.

We suspect this will also be the case when it comes to vaccines that are undergoing trials. Even if the first ones approved do not achieve the ideal level of effectiveness, we will take it in the name of timeliness. We trust that vaccine effectiveness will improve with time.

The mass availability of vaccines is without doubt a game changer. But we are still a very long way off, from approval to mass inoculation and eventual herd immunity, if possible.

This is the reason we think widespread rapid testing is the other crucial game changer — and why Malaysia should embrace this strategy whole-heartedly.

Rapid, regular and large-scale screening testing can be highly effective in identifying infected persons, including those who are asymptomatic, and preventing further transmissions — as proven in countries such as South Korea and Germany.

Better screening will, in turn, lead to safer reopening and gradual resumption of pre-pandemic daily activities that we used to take for granted, such as going to the mall, restaurants, movies, concerts, conferences, weddings and funerals. Equally important, the earlier the diagnosis, the more treatment options there will be for the infected and the best chance of recovery.

There is no question that widespread screening testing — and repeat testing — with quick turnaround time is crucial for normalisation of cross-border travel, for both business and leisure. The current infectivity spike in Malaysia proves how quickly the virus can spread even from interstate travel.

Singapore, for instance, has stressed the urgency of opening its borders and is looking to replace its 14-day quarantine requirement upon arrival with stricter and repeated testing and close tracking.

The current gold standard for Covid-19 diagnosis is the reverse transcription polymerise chain reaction (RT-PCR) test, which detects the genetic material of the virus, its ribonucleic acid (RNA). It has a high accuracy rate — analytical sensitivity and specificity of more than 95%.

The downside — test analysis has to be undertaken by trained healthcare professionals in a laboratory with specialised equipment and requires at least four to five hours to process, and often up to a few days for results, depending on capacity and logistics. Delays in reporting results can be costly — home quarantines are easily circumvented, as history has proven. The test is also relatively expensive.

Thus, while RT-PCR is the best diagnostic test we have currently, it is not well suited for mass screening testing, especially when quick turnaround time is required.

There are several approved antigen tests being used in other parts of the world. Unlike RT-PCR, antigen tests seek to detect certain proteins on the surface of the virus. The upside — they are relatively inexpensive and can be used at pointof-care (no need for specialised labs), the process is simple and they return results in as little as 15 minutes.

For instance, Abbott is selling an antigen test kit the size of a credit card for US$5 ($6.80). Apply the swab specimen to the testing card, add testing reagent, wait 15 minutes and the result can be read directly off the card, similar to pregnancy test strips.

The downside is that they are generally less sensitive than RT-PCR. According to the US Centers for Disease Control and Prevention (CDC), the first antigen tests to have received US Food and Drug Administration (FDA) approval demonstrate sensitivity ranging from 84% to 97.6% compared with RT-PCR. Basically, it means higher odds of false negative results. They are generally on a par with RT-PCR in terms of specificity, that is, false positives are unlikely.

In July, Malaysia’s Ministry of Health (MOH) was said to be reviewing the use of antigen test kits at airports after results showed a sensitivity of only 85%. There were cases of false negative results when the more sensitive RT-PCR returned a positive result.

We are not medical experts by any measure, but we believe that rapid antigen testing must be used even more extensively, to complement RT-PCR, instead of being written off.

No test is perfect — especially in real world, as opposed to idealised, conditions — in terms of meeting the ideal requirements of speed, accuracy, ease of application and costs.

Even the gold standard RT-PCR returns false negative results in the first four to five days of infection, when the viral load is too low for detection. Bear in mind also that all testing methods are subject to the integrity of the specimen during collection, handling, transportation and time to testing.

So, while rapid tests may miss a few cases, they do not invalidate the positive results or, critically, the benefits of early detection — before they become community risks.

In fact, according to CDC, modelling evidence shows that frequency of testing and speed of reporting is more effective in outbreak control than incremental increase in test sensitivity.

When the pre-test probability is high — for example, when the person is from known high-risk areas and/or has had close contact with confirmed cases — negative results can be confirmed with RTPCR. They can also undertake repeat antigen testing for the next few days. Given the fast turnaround and cheaper price, we would be no worse off in terms of total time and cost of a RT-PCR test.

Testing methods and processes are constantly evolving, being refined and improved upon — particularly in terms of ease of use, scalability, accessibility, timeliness and price.

Case in point: The Yale School of Public Health developed a promising test protocol that has gained FDA approval for emergency use authorisation. The National Basketball Association has been successfully using this test on its players and staff.

The test is based on RT-PCR, which still has to be conducted in a certified lab by trained technicians. The key difference is that it does not require special nucleic acid preservatives for sample collection (any sterile container will do) and replaces the costly and difficult procedure of extracting the virus’ RNA with a simple proteinase K and heat treatment step.

Yale claims its test can run 90 samples in about three hours. Since this is an opensource test protocol and not a physical kit and does not require proprietary equipment or reagents, it is easily scalable. That makes it less prone to supply limitations, and is cheaper and faster than traditional RT-PCR tests, but the process is still complex and more expensive than rapid antigen tests. This is a saliva-based test, which is less invasive than throat/nose swab-based tests, though slightly less sensitive as a sample type.

In summary, people may have been lulled into complacency after successfully subduing the first wave. The pandemic is far from over. In fact, we may have to live with the virus for a long time. If so, we need a game plan in this new reality to move forward.

That must include widespread test and trace — we should keep an open mind and continuously evaluate all the tools and measures available to contain the outbreak, given that medical science is advancing at lightning speed — and continued adherence to SOP.

In addition, we must make more effective use of the data collected from the nationwide MySejahtera app. For example, the massive amounts of movement data can be correlated with positive cases to pinpoint localities of infection. The rapid turnaround in data, on a daily basis, that is made publicly available will, in turn, alert the people and mitigate further transmission. By leveraging artificial intelligence and behavioural science, we might be able to discern patterns and predict its spread and future outbreaks.

The decision-making process must stem from facts and in the context of real world practicalities. Trade-offs may be inevitable, but ideological fixation and fear mongering will benefit no one.

The Global Portfolio gained 1.7% for the week ended Oct 8, similar to the broader market gain of 1.8% and lifting total portfolio returns to 35.9% since inception. This portfolio is outperforming the benchmark MSCI World Net Return index, which is up 20.7% over the same period.

The top gainers for the week were Taiwan Semiconductor Manufacturing Co (7.2%), Qualcomm (4.5%) and Builders FirstSource (3.7%), while the top losers were Vertex Pharmaceuticals (-2.3%), Ericsson (-2.2%) and Johnson & Johnson (-0.7%).

Disclaimer: This is a personal portfolio for information purposes only and does not constitute a recommendation or solicitation or expression of views to influence readers to buy/sell stocks, including the particular stocks mentioned herein. It does not take into account an individual investor’s particular financial situation, investment objectives, investment horizon, risk profile and/or risk preference. Our shareholders, directors and employees may have positions in or may be materially interested in any of the stocks. We may also have or have had dealings with or may provide or have provided content services to the companies mentioned in the reports.

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