KUALA LUMUR, Malaysia--The government hospitals in the Klang Valley are at breaking point. The acute care wards for seriously ill Covid-19 cases are packed to capacity and the emergency units are overflowing with patients who have difficulty in breathing. The intensive care wards are full. The system is no longer able to provide adequate care to the 20 – 25% of Covid-19 patients who require high quality and timely treatment with oxygen, steroids and anticoagulants to pull through and survive their ordeal.
Furthermore, the exponential rise in “brought-in-dead” (BID) Covid-19 cases, particularly in the Klang Valley region, is cause for alarm. According to recent CPRC figures, Selangor recorded the highest number of BID cases this year at 181 (27%), followed by KL at 78 (11.6%) out of a total of 670 BID cases for 2021. These figures were reported as of 2 July 2021, when there were a total of 4,856 deaths since 1 Jan 2021. By the time this statement is published, the figures would have risen.
Covid-19 is a self-limiting disease for about 75% of the patients who contract it. The infected person’s body produces antibodies to neutralize the virus and within a week the multiplication of the virus is curbed, and the patient is on the road to recovery. Nevertheless, about a third of patients will go on to develop debilitating long-term symptoms (termed “Long Covid”).
However, in about 20 to 25% of the cases of Covid-19, the immune system goes into over-drive (the “cytokine storm”) and starts damaging the lungs as well as other organs. This dangerous and potentially deadly phase occurs about 7 to 10 days after the person first develops symptoms of infection. If this immunological over-reaction is recognized early, it can be nipped in the bud with the use of steroids and anticoagulants while supporting the patient with supplemental oxygen. But these interventions have to be initiated in a timely fashion for maximum benefit.
We need to recognize that even if the number of new cases in KL-Selangor miraculously drops to zero tomorrow, the over-stretched hospital services in the Klang Valley will continue to be inundated by about 640 new Category 4 Covid-19 cases each day for the next 2 to 3 weeks. This is because there is a time lag of about a week to 10 days between first symptoms to the development of breathlessness due to immunological over-reaction. The average number of cases diagnosed daily in the KL-Selangor region was 2962 for the period 24 to 30 June 2021, and 3477 from 1 to 5 July. Category 4 Covid-19 cases will require at least 5 to 7 days of in-patient treatment to stabilize. This will push up bed occupancy rates which are already exceeding 100% in some government hospitals.
On the average, 10% of the patients requiring oxygen support (the Category 4 cases) will require ICU care within a week of admission. So the hospitals in the Klang Valley will need 64 more ICU beds every day for the next 3 weeks. If we cannot provide this level of care, morbidity and mortality due to Covid-19 will go up. Already, the case fatality rate in this current wave of Covid-19 has reached 1.3% – in other words, 13 patients die out of every 1,000 patients diagnosed. Compare this with 2020, when only 3.8 died out of every 1,000 cases. The current variants appear to be more vicious, and if we are unable to provide optimum care, the case fatality rate will go up even more.
Increasing the rate of vaccination and tightening physical distancing measures are important public health measures, but these will not solve the problems that our over-stretched public hospitals in the Klang Valley are facing currently. We understand the Ministry of Health has started to mobilise doctors and nurses from public hospitals in other states to help those in the Klang Valley. However, we need to urgently mobilise more resources to forestall the collapse of medical care in the Klang Valley.
Among the measures we need to implement are:
1. Transfer a portion of the new cases of Category 4 Covid-19 to hospitals in surrounding states – Perak, Pahang, Negeri Sembilan and Melaka. The Category 5 cases are too ill to be transferred safely and need to be handled in the hospitals where they are.
2. The Emergency Declaration specifically empowered the government to temporarily acquire private hospital facilities to handle the Covid-19 crisis. The time to use this provision is NOW. The government has to take over a portion of the ICU beds of the private hospitals in the Klang Valley so that the pressure on government ICUs can be relieved. (A portion only because the private hospitals will need some ICU capacity to deal with the really ill patients that they have. But they will have to reschedule elective cases that require post-operation ICU management.)
3. We should be prepared to borrow ventilators from Singapore, China and Australia so that we can quickly expand our ICU capacity.
4. The monitoring of patients being managed at their homes has to be upgraded so that deterioration to the immunological phase of the illness can be recognized early and appropriate treatment initiated in a timely fashion. The Covid-19 Assessment Centres at district level should enlist a corps of volunteers (retired doctors, nurses, others who are able) who are each given a set of patients to follow up by phone every day for the first 2 weeks after diagnosis of Covid-19. If their symptoms indicate possible deterioration, these patients should be admitted for assessment and optimal treatment. A system of reporting should be put in place such that the volunteers give daily feedback on all their wards.
All the above 4 measures are doable, but they need to be initiated from the highest levels of the Ministry of Health and the MKN (Majlis Keselamatan Negara). The political temperature is going up with the approaching parliamentary session and the end of the Emergency. There is a real danger that political intrigues will distract the authorities from the fact that many Malaysians are now struggling for their lives and that our health care system in the Klang Valley is at the point of collapse.
Let’s prioritize the safety of our Covid-19 patients and collectively raise our voices to urge the government to immediately implement the above measures to prevent a health care disaster.
Immediate Steps Needed to Forestall Collapse of Health Care Services in the Klang Valley