Post webinar Q&A with Dr. Benedict Sim, 12 April 2021

1. Dr. Ben, in the webinar on 7 April 2021, what did you mean by “the mortality rate of 0.4% does not mean anything anymore?”

The Case Fatality Rate (CFR) is the proportion of the number of deaths divided by the number of confirmed patients. In Covid-19 pandemic, the CFR is an important indicator of the risk of the disease, and it can be used to compare the severity of the epidemic between countries. COVID-19 pandemic is still ongoing, and so the actual number or “true CFR” in each country is only known at the end of the epidemic, when the outcomes of all cases is recorded. In other words, the current CFR is dynamic. And, if CFR is stratified according to the age of the affected patients, the number would differ according to the age groups. For example, in Malaysia, the current low CFR of 0.37% (as of 12 April 2021) is a result of a larger proportion of younger confirmed cases in comparison to older people who have severe disease and risk of mortality.

For older patients who get severe COVID-19 infection and require ICU care, the mortality rate is much higher at about 34.3% compared to the younger patients aged 40-49 years who only recorded about 0.9% CRF. Case Fatality rate (CFR), Infection Fatality Rate (IFR) and crude mortality rate (CMR) are measured by various countries to help develop prevention and intervention measures in Covid-19.

Figure 1: Source of information from ClinData_COVID19 research team, MOH Malaysia's National Consensus Guidelines and Institute for Clinical Research, NIH.

2. Sungai Buloh Hospital is the main COVID-19 referral hospital. Can you give an account of management of non-Covid patients at this hospital?

Sungai Buloh Hospital is designated as a COVID-19 hospital by the Ministry of Health Malaysia. Primarily, it is also a tertiary hospital with multi sub-specialty services. In early 2020, Sungai Buloh Hospital started re-allocation of hospital services to facilitate the admission and care of COVID-19 patients. For non-COVID-19 patients, Sungai Buloh Hospital prioritized out-patient specialist services and for any immediate care, patients are managed accordingly or referred after being stabilized to other MOH hospitals in the Klang Valley. The hospital also promoted telemedicine in outpatient settings and maintained standard care for those in need of emergency services. As Sungai Buloh Hospital is currently focussing on the COVID-19 services, we are aware of a reduced number of non-Covid patients, mostly due to the public’s perception of COVID-19 risk in our hospital setting. The impact to non-COVID-19 patient management is yet to be ascertained, but in keeping with the experience from other hospitals in COVID-19, there is a likelihood of default in follow-ups and a drop in elective surgeries.

Currently, a study is being carried out to investigate the pattern of admission and workload during the COVID-19 pandemic. We will have to wait for the results of this study to see the true impact of the pandemic on the morbidity and mortality trends for non-COVID-19 patients.

3. What happens to the patients after they are discharged from hospital? How does underlying illness complicate COVID-19?

We are beginning to see some patients who have recovered presenting with post-acute sequelae of SARS-Cov2 infection. This recently recognized condition is referred to as Long COVID. Studies have shown that some people may remain symptomatic beyond 6 months after recovery while other studies have highlighted readmission and mortality several months after discharge. However, these are only seen in a few patients and there is uncertainty as to how much COVID-19 plays a part in their eventual mortality. For MOH, case definitions are used to determine if a person succumbed due to a direct cause of COVID-19. Importantly, our case definitions are based on WHO definitions to ensure that our reporting on case fatality rates is consistent across different countries.

This is a weekly live webinar jointly organized by Malaysian Society of Infection Control and Infectious Diseases (MyICID) & Institute for Clinical Research (ICR), National Institutes of Health (NIH) Malaysia.