Brunei Covid-19

Publications in 2020:

• What do we know about SARS-CoV-2 transmission? A systematic review and meta-analysis of the secondary attack rate and associated risk factors (Wee Chian Koh, Lin Naing, Liling Chaw, Muhammad Ali Rosledzana, Mohammad Fathi Alikhan, Sirajul Adli Jamaludin, Faezah Amin, Asiah Omar, Alia Shazli, Matthew Griffith, Roberta Pastore, and Justin Wong) - published in PLOS ONE

• Estimating the impact of physical distancing measures in containing COVID-19: An empirical analysis (Wee Chian Koh, Lin Naing, and Justin Wong) - published in International Journal of Infectious Diseases

• Epidemiological investigation of the first 135 COVID-19 cases in Brunei: Implications for surveillance, control, and travel restrictions (Justin Wong, Liling Chaw, Wee Chian Koh, Mohammad Fathi Alikhan, Sirajul Adli Jamaludin, Wan Wen Patricia Poh, and Lin Naing) - published in The American Journal of Tropical Medicine and Hygiene

• Analysis of SARS-CoV-2 transmission in different settings, Brunei (Liling Chaw, Wee Chian Koh, Sirajul Adli Jamaludin, Lin Naing, Mohammad Fathi Alikhan, and Justin Wong) - published in Emerging Infectious Diseases

• Probable causes and risk factors for positive SARS-CoV-2 test in recovered patients: Evidence from Brunei Darussalam (Justin Wong, Wee Chian Koh, Riamiza Natalie Momin, Mohammad Fathi Alikhan, Noraskhin Fadillah, and Lin Naing) - published in Journal of Medical Virology

• Containing COVID-19: implementation of early and moderately stringent social distancing measures can prevent the need for large-scale lockdowns (Wee Chian Koh, Mohammad Fathi Alikhan, David Koh, and Justin Wong) - published in Annals of Global Health

• Responding to COVID-19 in Brunei Darussalam: lessons for small countries (Justin Wong, Wee Chian Koh, Mohammad Fathi Alikhan, Anita B Z Abdul Aziz, and Lin Naing) - published in Journal of Global Health

First Wave (March - May 2020)

Brunei Covid-19 snapshot

Brunei Covid-19 public reaction

Brunei Covid-19 summary statistics

Brunei Covid-19 clusters of confirmed cases

Brunei Covid-19 case history

Brunei Covid-19 economic relief and stimulus measures

Brunei Covid-19 public health measures

Early and stringent: Brunei’s interventions to fight Covid-19

The fight is not over—far from it—but the signs are encouraging. Four weeks since the first confirmed case of Covid-19 in Brunei, the situation appears to be under control (see chart below). Policy measures—early and stringent—have been instrumental: contact tracing and testing, isolation and quarantine, schools and mosques closed, mass gathering prohibited, travel bans. So have the timeliness and transparency of situational reports, as well as the collective consciousness and effort of social distancing.

Some countries have been affected more severely than others due to factors such as proximity and connectivity to outbreak areas, population density, and community behavioural patterns. However, early and stringent interventions are crucial in containing the virulent virus.

The scatter plot below shows the variation in countries’ interventions and the total number of confirmed cases. The horizontal axis is the stringency level five days after the first confirmed case was recorded. The vertical axis is the maximum stringency level reached. The size of a bubble is proportional to the total number of cases. Some observations:

• Countries to the right of the red line (stringency index of 40 at day 5)—those with early and stringent interventions—have recorded a much lower number of cases (although some may have limited testing capacity, or are far from the epicentre of the pandemic).

Brunei intervened early—by day 8, it has imposed all the measures outlined above. Similarly, Hong Kong and Macau, with close links to mainland China, took early and stringent measures.

• Conversely, countries to the left of the red line have had severe outbreaks, such as China, Iran, Italy, Spain, South Korea, and the United States. These countries have seen total cases double every one to three days (see the snapshot section on Covid-19 trajectories).

Italy and Spain have taken drastic measures, including lock downs, in response to the surge in cases. However, these measures were imposed too late and could not prevent healthcare systems from being overwhelmed.

There are exceptions, nonetheless. Although Singapore’s early interventions were comparatively less stringent, the country’s swift action to aggressively perform contact tracing and testing helped to slow infection rates.

Among the severely-affected countries, China and South Korea have managed to slow down the spread of the virus. China imposed a lock down in several provinces while South Korea employed mass, indiscriminate testing and rigorous contact tracing.

How stringent are Brunei’s Covid-19 policy measures?

Brunei has taken swift public health measures after the first Covid-19 case was confirmed on March 9. Some people have questioned whether the government is overreacting to the situation, while others believe that tougher measures should be enforced, such as a “lock down” seen in Malaysia and the Philippines.

I have created a Government Response Stringency Index for Brunei based on the Oxford Covid-19 Government Response Tracker measurement framework. The index is a composite measure of seven common policy measures: school closing; workplace closing; cancel public events; close public transport; public info campaigns; restrictions on internal movement; and international travel restrictions.

The chart below shows how Brunei’s stringency index changes as the number of cases increase, and how it compares to Singapore’s and Malaysia’s. Some observations:

• At day 20 after the first case was reported, Brunei had more total cases (120) than Singapore (47) and Malaysia (18).

• Brunei and Singapore put in place some policy measures prior to any confirmed case, whereas Malaysia did not.

• Brunei swiftly stepped up policy measures that are commensurate with the rise in cases.

The scatter plot below shows the maximum level of stringency a country has reached and the total number of cases. Countries to the top-left corner have more stringent measures given their number of confirmed cases, whereas those to the bottom-right have less stringent measures. Brunei lies somewhere in the middle. For instance, it is comparatively more stringent than Singapore, but less so compared to Macao. Malaysia, on the other hand, has enforced a lock down after a surge in cases.

Is Brunei’s healthcare system prepared for Covid-19?

The Covid-19 pandemic has already overwhelmed the healthcare systems of several countries, such as Italy and Spain. In the coming weeks, the healthcare systems of many countries are expected to be overburdened following a surge in cases. The table below highlights the severity of the pandemic and the strain in critical care capacity.

The scatter plot below shows a cross-country comparison of health expenditure as a share of GDP and the number of critical beds per 100,000 people. Some observations:

• Brunei’s spending on health is comparatively low at 2.3% of GDP.

• However, Brunei has invested in critical care capacity with 13.1 critical care beds per 100,000 people, higher than the average in European countries (11.5), Singapore (11.4), and South Korea (10.6).

As of March 30, three weeks after the first Covid-19 case was reported, Brunei’s total cases stood at 127, with three in critical condition and one death. Although the growth in cases has not been exponential—thanks to swift policy measures—a lapse in vigilance can quickly put the country on a different trajectory. Using the number of ICU beds—58 in hospitals and 27 in the National Isolation Centre—as a proxy of critical care capacity (number of ventilators are not publicly available), Brunei appears positioned to respond to patients that require critical support in the next month, based on the current trend of new cases. A new isolation centre is under construction to expand the nation's healthcare capacity.

Other hospital resources are also important factors to consider in assessing a country's preparedness to address the pandemic. The charts below compare the availability of Brunei’s hospital resources with those of other high-income countries. Brunei has a good healthcare system but resources are nowhere close to the most advanced economies such as Germany and Switzerland. Social distancing measures to flatten the epidemic curve are therefore essential to keep the daily number of cases at a manageable level for medical providers.

Is Brunei conducting enough tests for Covid-19?

Many people have been asking whether the Ministry of Health is conducting enough tests to detect the prevalence of Covid-19. During the period March 14-23, around 270 tests were done daily, on average. With the increase in the number of close contacts in quarantine and those returning from abroad who have to undergo mandatory self-isolation, the average number of daily tests has risen to 450 during March 24-27. A new virology laboratory is currently under construction and is expected to be completed in early April.

The scatter plot below shows a cross-country comparison of the number of tests done and the total number of confirmed cases. Some observations:

• The more tests a country has done, the more confirmed cases it has—as evident by the positive correlation in the chart.

• Some countries have conducted more tests to detect a confirmed case. This may suggest a comparatively lower prevalence of Covid-19 in those countries. For instance, the United Arab Emirates has done 125,000 tests and has 86 confirmed cases only (as of March 16).

• By contrast, the Philippines has 230 confirmed cases after having conducted 1,269 tests (as of March 20). This may be an indication of under-testing—the number of actual infected cases is likely to be much higher than the number of confirmed cases.

• Brunei lies somewhere in the middle. It has conducted 4,519 tests and has 114 confirmed cases (as of March 26).

What do we know about Covid-19?

• Novelty. Covid-19 (coronavirus disease 2019) is an infectious disease caused by the novel virus SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2). SARS-CoV-2 is the seventh coronavirus known to infect humans. It is a strain of the same virus as SARS-CoV-1, which infected about 8,000 people in 2002-03. Covid-19 was first identified in December 2019 in Wuhan, Hubei Province, China, and believed to have originated in a large seafood market.

• Origin. SARS-CoV-2 has close genetic similarity to bat coronaviruses, with a 96% DNA match, suggesting that bats are the natural reservoir hosts.[1] The link to human is not direct but is through an intermediate host, suspected to be pangolins.[2] Evidence dismisses claims that the virus was made in a laboratory or otherwise engineered.[3]

• Infection. Human-to-human transmission occurs primarily through respiratory droplets from coughs and sneezes.[4] Indirect transmission through fomites (e.g. contaminated surfaces) is another cause of infection. Other transmission routes via aerial droplets and fecal-oral are also possible but further evidence is required to assess the possibility. The SARS-CoV-2 virus can remain viable and infectious in aerosols for hours and on surfaces up to days.[5] People with mild or no symptoms may also be contagious. Several studies find that asymptomatic cases are responsible for a large proportion of infections.[6] Early estimates of the basic reproduction number (R0) of the virus by the World Health Organization (WHO) is in the range of 1.4 to 2.5, which means that each infection is expected to result in 1.4 to 2.5 new infections.[7] Other studies report higher R0 estimates of up to 3.3.[8][9]

• Symptoms. The most common symptoms are fever and cough.[10][11][12] Other symptoms may include fatigue, sputum production, headache, muscle ache, chills, sore throat, diarrhea, nausea, and nasal congestion. Some patients may further develop shortness of breath and trouble breathing, which requires prompt medical attention. Hospitalized patients often show pneumonia with ground-glass shadow on chest computed tomography (CT).

• Prognosis. At present, there is no vaccine or specific antiviral treatment. Most people with mild illness will recover on their own. For severely ill patients, supportive care is essential. In mainland China, 91.7% of all recorded cases have recovered while the case fatality rate (CFR) is 4.0% (as of March 27). The elderly are most at risk. Early data on the CFRs in mainland China among patients aged 70-79 and 80+ were 8.0% and 14.8%, respectively.[13] Patients with pre-existing medical conditions also had higher CFRs. Italy, which has the second oldest population structure in the world and where one-quarter of the population are smokers, has recorded a much higher CFR of 10.6% (as of March 27).

[1] Zhou, P., Yang, X., Wang, X. et al. (2020). A pneumonia outbreak associated with a new coronavirus of probable bat origin. Nature 579, 270–273. https://doi.org/10.1038/s41586-020-2012-7

[2] Cyranoski, D. (2020). Mystery deepens over animal source of coronavirus. Nature 579, 18-19. https://doi.org/10.1038/d41586-020-00548-w

[3] Andersen, K.G., Rambaut, A., Lipkin, W.I. et al. (2020). The proximal origin of SARS-CoV-2. Nature Medicine. https://doi.org/10.1038/s41591-020-0820-9

[4] Wu, D., Wu, T., Liu, Q., and Yang, Z. (2020). The SARS-CoV-2 outbreak: what we know. International Journal of Infectious Diseases. https://doi.org/10.1016/j.ijid.2020.03.004

[5] van Doremalen, N., Bushmaker, T., Morris, D.H., et al. (2020). Aerosol and Surface Stability of SARS-CoV-2 as compared with SARS-CoV-1. The New England Journal of Medicine. https://doi.org/10.1056/NEJMc2004973

[6] Qiu, J. (2020). Covert coronavirus infections could be seeding new outbreaks. Nature 579. https://doi.org/10.1038/d45186-020-00822-x

[7] World Health Organization (2020). Statement on the meeting of the International Health Regulations (2005) Emergency Committee regarding the outbreak of novel coronavirus (2019-nCoV).

[8] Cheng, Z.J. and Shan, J. (2020). 2019 Novel coronavirus: where we are and what we know. Infection 48, 155-163. https://doi.org/10.1007/s15010-020-01401-y

[9] Imperial College COVID-19 Response Team (2020). Report 12: The global impact of COVID-19 and strategies for mitigation and suppression.

[10] Huang, C., Wang, Y., Li, X. et al. (2020). Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. The Lancet 395, 497-506. https://doi.org/10.1016/S0140-6736(20)30183-5

[11] Guan, W., Ni, Z., Hu, Y. et al. (2020). Clinical characteristics of coronavirus disease 2019 in China. The New England Journal of Medicine. https://doi.org/10.1056/NEJMoa2002032

[12] Zhao, X., Zhang, B., Li, P. et al. (2020). Incidence, clinical characteristics and prognostic factors of patients with COVID-19: a systematic review and meta-analysis. medRxiv https://doi.org/10.1101/2020.03.17.20037572

[13] Wu, Z. and McGoogan, J.M. (2020). Characteristics of and important lessons from the coronavirus disease 2019 (COVID-19) outbreak in China: summary of a report of 72,314 cases from the Chinese Center for Disease Control and Prevention. JAMA. https://doi.org/10.1001/jama.2020.2648